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LIBRARY OF CONGRESS. 



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UNITED STATES OF AMERICA. 



A MANUAL 



DISEASES 



THROAT AND NOSE 



FPvANCKE HUNTINGTON BOSWOETH, A.M., M.D., 

LECTDKER ON DISEASES OF THE THROAT IN THE BELLEVUE HOSI'ITAL MEDICAL COLLEGJ 

AND PHYSICIAN-IN-CHAKGE OF THE CLINIC FOR DISEASES OF THE THROAT IN THE 

OrT-DOOR DEPARTMENT OF BELLEVUE HOSPITAL; FELLOW OF THE NEW 

YORK ACADE.MT OF MEDICINE, OF THE AMERICAN LARYNGOLOGI- 

CAL ASSOCIATION, AND MEMBER OF THE MEDICAL 

SOCIETY OF THE COUNTY OF NEW YORK. 



KEW YORK: 

WILLIAM WOOD & CO M F A K Y 

ISSl. 






7r- 







Copyright, 

WILLIAM WOOD & COMPANY, 

18S1. 



Trow's 

Printing and Bookbinding Company 

201-213 .ErtXJ? 12M Sireei 

NEW YORK. " 



JAMES R. WOOD, M.D., LL.D. 

EMERITUS PROFESSOR OF SURGERY IN THE EELLEVUE HOSPITAL 5IEDICAL COLLEGE, 

ONE OF ITS FOUNDERS, AND THE FIRST TO ORGANIZE SrSTEMATIC 

CLINICAL INSTRUCTION IN SURGERY IN 

BELLEVUE HOSPITAL ; 

AN ACCOMl'LISUED SURG-EOIS' ; A SUCCESSFUL TEACHEU; AND A TRUE FKIBND; 

3Jti5 Tolumt 15 glfftcttonatelj llfliualclj, 

BY HIS 

FORMER PUPIL. 



PREFACE. 



I HAVE embodied in the following pages tlie results of an 
experience, in dealing with throat affections, extending now 
over nearly ten years, and which has embraced the observation, 
treatment, and, in the large proportion of instances, the ob- 
served results of treatment, of something over eight thousand 
recorded cases. These have been partially in private practice, 
but mainly at the Bellevue Clinic for Diseases of the Throat. 
In making these results public, I have endeavored to confine 
myself to my own personal experience, recording, with candor 
and fidelity, both the method and measure of my success in 
those affections in which success has followed treatment, and, 
at the same time, and with the same candor, acknowledging 
the diflaculties and disappointments which have attended the 
management of those diseases in the treatment of which I 
have failed of full success. 

In describing special methods of treatment, I have endeav- 
ored to enter into full detail, preferring to err in this direction, 
rather than to fail of making myself clearly understood. The 
methods recommended are all such as I have made use of, and 
with the result given ; the methods recommended by others, I 
have, as a rule, passed over, except when I have found them 
of value. 

In the classification of diseases, I have followed that plan 
which is based on the general laws which govern the manifes- 
tation and development of morbid processes in all mucous 



vi PEEFACE. 

membranes, and wliich at the same time harmonizes most com- 
pletely with clinical observation. This is outlined in the chap- 
ter on mucous membranes, but may be briefly noticed here. 
An inflammation of a mucous membrane manifests itself in 
the catarrhal, croupous, or diphtheritic form. A catarrhal in- 
flammation may be acute or chronic, while the latter forms are 
always acute. A chronic catarrhal inflammation develops cer- 
tain structural changes in tlie deep layer of the membrane, 
which may expend themselves in the membrane proper, consti- 
tuting a chronic catarrhal inflammation, or they may expend 
tliemselves in the glands and follicles, constituting a chronic 
follicular inflammation. The croupous form of inflammation 
consists of a morbid process which is attended with an exuda- 
tion which coagulates ; if this is poured out on the surface a 
false membrane is formed, if it occurs in the glands or follicles, 
an acute follicular inflammation is the result. Diphtheritic in- 
flammation occurs only in connection with blood-poisoning, as 
in diphtheria. 

If now we turn to observed clinical facts, we find that in- 
flammatory affections involving tlie lining membrane of the 
upper air tract, whether of the nose, pliarynx, or larynx, obey 
these general laws, except so far as they are modified by differ- 
ences in the anatomy of the membrane, and the functions and 
environment of the part. Certain parts are richly endowed 
with follicles, as the pharyngeal vault, the lower pharynx, 
and that portion of the fauces which is called the tonsil ; 
hence, in these regions we find there is an especial liability to 
the occurrence of follicular disease, both acute and chronic. 
The nasal cavities proper, and the larynx, on tiie other hand, 
are especially subject to purely catarrhal inflammation, and 
not, as a rule, to the follicular disease. 

AYe may then summarize somewhat briefly : 
Acute catarrhal inflammation may occur in the nose, pharynx, 

or larynx, resulting in acute coryza, acute pharyngitis, 

acute laryngitis, etc. 



PREFACE. Vii 

Chronic catarrhal inflammation may occur in any portion of 
the air-passages, resulting in chronic coryza, chronic 
pliaryngitis, clironic laryngitis, etc. 
Acute follicular inflammation may occur in the upper or 
lower pharynx, or in the tonsils, resulting, in acute folli- 
cular tonsillitis, acute follicular pharyngitis, etc. 
Chronic follicular inflammation may occur in the pharynx or 
tonsils, resulting in chronic follicular pharyngitis, enlarged 
tonsils, etc. 
Crou'pous inflammation may occur in the pharynx or larynx, 
resulting in croupous pharyngitis or membranous sore 
throat ; or in croupous laryngitis, or true croup. 
Diphtheritic inflammation may occur in any portion of the 
upper air tract, as a local manifestation of the blood dis- 
ease, diphtheria. 
This in brief is the plan which I have followed in the classi- 
fication of the inflammatory affections of which the following 
pages treat. In this manner, that nomenclature is dispensed 
with which includes such names as acute and chronic sore 
throat, granular sore throat, granular pharyngitis, clergyman's 
sore throat, etc. These names, it seems to me, are indefinite, 
and somewdmt meaningless, and should therefore not be used. 
On the other hand, in the classification which has been adopted, 
the name of the disease expresses fully the character of the 
morbid process and the elemental constituent of the mem- 
brane, as well as the region, involved. In those affections in 
which there occurs two grades of acute inflammation, as in 
acute and subacute tonsillitis, I have used the prefix to char- 
acterize the degree of the inflammatory process. This is occa- 
sionally used to denote a process midway between the acute 
and chronic ; it seems to me preferable that it should qualify 
the tyj^e of the morbid activity, and describe an inflammation 
still acute, but of a mild form. 

It was not my design, in undertaking this work, to prej^are 
a complete treatise on the throat, but ratlier to describe tiiose 



Vlll PEEFACE. 

affections met with in ordinary practice ; I have for this reason 
omitted man}^ diseases which perhaps may more properly be- 
long in a work of the dimensions to which this has nninten-' 
tionally grown, notably diphtheria and the throat manifesta- 
tions of the exanthemata ; these, I have thought, more properly 
belong to general medicine, and I have omitted them. 

I have departed somewhat from the original plan of the 
book, in treating of some subjects at considerable length, as 
laryngeal phthisis, bilateral paralysis of the abductors, etc. I 
have done this designedly, with the object of introducing per- 
sonal views and me.thods of treatment which are not given in 
other works, and which I regard as worthy of consideration. 

I am under obligation to Dr. J. Solis Cohen, of Phila- 
delphia, for his kindlj^ permission to make use of the excel- 
lent woodcuts which I have borrowed from his work on The 
Throat. I am also under obligation to Dr. Morrell Mackenzie, 
for the woodcuts which I have appropriated, without permis- 
sion, from his recent work on The Throat and JSTose. My ex- 
cuse for this is, that his work appeared in this country after 
my manuscript had been sent to the printer, and the cuts have 
been inserted while the book has been going through the press ; 
my time was too limited to await a response, and it would not 
have been a very gracious act to seek his permission to use 
them after I had already appropriated them. 

I trust that Dr, Mackenzie will accept this explanation, with 

the additional excuse that the exceptional character of the 

illustrations of his work proved a still greater temptation to 

me to make use of them. 

F. H. B. 

No. 26 West Forty-sixth Street, 
Xew York City. 

January 1, 1881. 



TABLE OF CONTENTS. 



PAGE 

INTEODUCTION xix 



CHAPTER I. 

THE USE or THE LAEYNGOSCOPE 1-32 

The Lakyngoscope. — Examination of the Lakynx. — Examination 
OP THE Pharynx. — -Examination of the Nasal Oavhy. 



CHAPTER 11. 

MUCOUS ]VIEMBEANES 83-43 

Anatomy. — Physiology. — Pathology. 



CHAPTER III. 

METHODS OF TEEATING MUCOUS JVIEIMBEANES AKI> THE 

USE OF INSTEmiENTS 44-63 



CHAPTER ly. 
TAKING COLD 64-73 



DISEASES OF THE FAUCES. 
CHAPTER V. 

CATAEEHAL AFFECTIONS OF THE PHAEYNX 74-97 

Anatomy and Physiology op the Phakynx. — Acute Cataeehal 
Pharyngitis, or Ordinary Soee Throat. — Chronic Catarrhal 
Pharyngitis. — ^Pharyngitis Sicca. — Elongated Uvula. 



X TABLE OF CONTENTS. 

CHAPTER yi. 

PAGE 

CROUPOUS, OR EXUDATIVE AFFECTIONS OF THE PHARYNX. 98-110 
Acute FoiiiiiciriiAK Phaetngitis. — Chkonic FollictjiiAK Phaeyngi- 

TIS. — MeJIBK ANGUS SORE ThKOAT, OE CeOUPOUS PHARYNGITIS. 

CHAPTER VII. 

ACUTE AFFECTIONS OF THE TONSILS 111-126 

Geneeal Consideeations. — Acua?E ToNsrLiiiTis, or Phlegmonous 
Tonsillitis. — Subacute Tonsillitis. — Acute Follicular Ton- 
sillitis. 

CHAPTER VIII. 

HYPERTROPHY OF THE TONSILS 127-142 

CHAPTER IX. 

SYSTElVnC DISEASES OF THE PHARYNX 143-161 

Syphilis of the Phaeynx. — Strumous Ulceeation of the Pha- 
rynx. — Tuberculosis of the Phaeynx. 

CHAPTER X. 

NEUROSES OF THE PHARYNX 162-165 

Heepes of the Phaeynx.— Hysteeo-Neueoses of the Fauces. 



DISEASES OF THE NASAL CAVITY. 
CHAPTER XI. 

CATARRHAL AFFECTIONS OF THE NOSE 166-178 

Anatomy and Physiology of the Nose. — Acute Coeyza. 



CHAPTER XII. 

CHRONIC NASAL CATARRH 179-211 

Chronic Coryza. — Hypertrophic Nasal Cataeeh. 



TABLE OF CONTENTS. XI 

CHAPTER XIII. 

PAGE 

GHEONIC NASAL CAT A'RB,!!— (Continued) 212-230 

Atbophic, OB Dkt Cataeeh.— Fetid Nasal Oataekh. — Oz^na. 

CHAPTER XIV. 

SYPHILIS OF THE NOSE 231-237 

Syphilitic Ozmsa, oe Syphilitig Uloeeation in the Nose. 

CHAPTER XY. 

SURGICAL AFFECTIONS OF THE NOSE 238-252 

TUMOES OP THE NoSE. — EPISTAXIS. — DEVIATION OF THE SePTUM. — 

FoBEiGN Bodies in the Nose.— Anossiia. 



DISEASES OF THE LARYNX. 
CHAPTER XVI. 

OATAEEHAL AFFECTIONS OF THE LAEYNX ,253-284 

Anatomy and Physiology op the Laeynx.^ — Subacute Laeyngi- 
tis. — Acute Laeyngitis. — Chbonic Catabehal Labyngitis.—- 
CEdema of the Labynx. 

CHAPTER XVII. 

LAEYNGEAL PHTHISIS 285-296 

CHAPTER XVIII. 

SYPHILIS OF THE LAEYNX 297-317 

Subacute Oataeeh op the Labynx in Syphilis. ^ — Mucous Patches. 
— Chbonic Catabehal Laeyngitis of Syphilis. — Supeeficial 
Ulcees op the Labynx in Syphilis. — Deep Ulcees of the 
Labynx in Syphilis, 

CHAPTER XIX. 
STENOSIS OF THE LAEYNX 318-324 



Xii TABLE OF CONTENTS. 

CHAPTER XX. 

PAGE 

NEUEOSES OF THE LAEYNX 325-347 

General Considebations. — Eecukeent Laetngeal Paealysis.— 
Double Eecueeent Laetxgeal Paealysis. — Paealysis of In- 
DiTiDUAii Muscles. — Unilateral Paealysis of the Ceico- 

AEYTENOIDEUS POSTICUS MuSCLE. — UNILATERAL PaEALYSLS OF 
THE CrICO-ARYTENOIDEUS LATERALIS MuSCLE.— BiLATERAL PAR- 
ALYSIS OF THE CeICO-AEYTENOIDEI LaTEEALES MuSCLES. — BlLA- 

TEEAL Paealysis op the Thyeo-aeytenoidei jMuscles. — Uni- 

LATEEAL PARALYSIS OF THE ThYEO-AEYTENOLDEUS MuSCLE. — 

Paealysis of the Aeytexoideus Muscle. — Treatment of 
Paralysis in General.— Hysterical Aphonta. 

CHAPTER XXI. 

KEUEOSES OF THE LAEYNX— (Continued) 348-364 

Bilateral Paralysis of the Abductor Muscles of the Larynx. 

CHAPTER XXII. 

TUMOES OF THE LARYNX 365-382 

Benign Tumors.— Chorditis Tuberosa.— The Eemoval of Lar- 
yngeal Tumors. — Seih-Malignant Tumors, or Sarcomata. — 
Malignant Tumors. 

CHAPTER XXIII. 

ABTIFICLiL OPENINGS ES^TO THE AIR -PASSAGES 383-402 

Laeyngotomy. — Laeyngo-teacheotomy. — Teacheotomy. — Thyrot- 
OMY. — Sub-hyoidean Phaeyngotomy. 

CHAPTER XXiy. 

EXTIRPATION OF THE LAEYN^X 403-410 

APPENDIX 411-420 

INDEX *21 



LIST OF ILLUSTEATIOI^S. 



FIG. PAGE 

1. The laryngeal mirrors 2 

2. Schroetter's head-band and mirror 2 

3. Pomeroy's head-band and nairror 3 

4. The author's head-band and mirror 3 

5. Head-mirror attached to a spectacleT frame 4 

6. Sass's laryngoscope 5 

7. Mackenzie's light condenser, mounted on the rack movement fixture. . . 5 

8. Examination with head-mirror and Mackenzie's light condenser 6 

9. Examination by Tobold's laryngoscope with ordinary stiident's lamp. . . 7 

10. Examination with head-mirror by use of ordinary gas-jet 8 

11. Holding the laryngeal mirror 9 

12. The laryngeal mirror in position 10 

13. Course taken by the rays of light in a laryngeal examination 11 

14. Epiglottic pincette of Von Bruns 12 

15. Relative joosition of larynx and image in the mirror 14 

16. Arched epiglottis . . 15 

17. Indented epiglottis , 15 

18. Asymmetrical epiglottis , 15 

19. Overhanging epiglottis 15 

20. Omega-shaped epiglottis 15 

21. Pointed and depressed epiglottis 15 

22. Laryngoscopic image, double size, glottis open 17 

23.' Laryngoscopic image — glottis closed during phonation 18 

24. Tuerck's tongue spatula 19 

25. Pocket-folding spatula 19 

26. United States Ai-my spatula 19 

27. Sass's sijatula 20 



Xiv LIST OF ILLUSTRATIOI^S. 

FIG. PAGE 

28. Sexton's spatula 20 

29. Metliod of introducing spatula and depressing tongue 21 

30. Fraenkel's nasal speculnm 23 

31. Goodwillie's nasal sijecnlnm 23 

32. Examination of nasal cavity anteriorly with hair-pin 23 

33. The author's nasal speculum 24 

34. Simrock's nasal speculum 24 

35. Elsberg's nasal speculum .... 24 

36. Holding the mirror for rhinoscopic examination 26 

37. Mirror in position for making rhinoscojjic examination, and parts 

seen 27 

38. Duplay's rhinoscope 28 

39. Author's canula for tying the palate 29 

40. Rhinoscopic image 31 

41. Glandular structure of the vault of the pharynx— natural size 31 

42. Vertical section of a mucous membrane 34 

43. Epithelial cells 35 

44. Eauchfuss' powder insufflator 45 

45. Lefferts' modification of Eauchfuss' insufflator 46 

46. Powder insufflator, with mouth-piece 46 

47. Smith's powder insufflator, movable tips 46 

48. Stoerck's powder insufflator 47 

49. Tuerck's brush 48 

50. Mackenzie's brush 49 

51. Ordinary sponge-holder 50 

52. Elsberg's spring-forceps sponge-holder, with Mackenzie's modification. 50 

53. Elsberg's improved sponge-holder 51 

54. Post-nasal syringe 51 

55. Post-nasal tube fitted to Davidson's syringe 51 

56. Hartewelt's laryngeal syringe 52 

57. Weber's nasal douche and method of using 53 

58. Thudichum's syphon douche 53 

59. Cohen's modification of Thudichum's syphon douche 53 

60. Method of arranging syphon douche 54 

61. Eichardson's atomizer, with double air-bulbs "55 

62. Sass's spray tubes, with automatic cut- off 56 

63. Single hand-ball atomizer 57 

64. Newman's spray tubes, with air-bulbs for foot-pressure 57 

65. Air-pump and receiver 58 



LIST OF ILLUSTRATIONS. XV 

FIG. PAGE 

66. Steam atomizer, after the principle of Siegle 62 

67. Mackenzie's eclectic inhaler. . . 63 

68. Anterior view of muscles of pharynx and palate 75 

69. Anterior view of naso-pharyngeal s^Dace 76 

70. Ordinary nvnla scissors 95 

71. Sayre's uvnlatome 95 

72. Elsberg's uvulatome 95 

73. Cutting the uvula 96 

74. Follicular pharyngitis 102 

75. Follicular phaiyngitis, aggravated form 102 

76. Actual cautery wires for destruction of enlarged follicles 104 

77. Section of a tonsil in a state of true hypertrophy 128 

78. Tonsil bistoury 137 

79. Tonsil vulsellum 138 

80. Mackenzie's modification of Physick's tonsillotome , 138 

81. Fahnestock's tonsillotome 139 

82. Improved German tonsillotome 139 

83. Hamilton's tonsillotome 140 

84. Mackenzie's double tonsillotome 140 

85. Mathieu's tonsillotome 141 

86. Outer wall of left nasal cavity 166 

87. Transverse section through the nasal cavity, seen from behind 167 

88. Nerves of the outer wall of the nasal cavity 168 

89. Terminal fibres of the olfactory nerves 169 

90. Vault of pharynx — fissured appearance of glandular tissue 172 

91. Ai'tero-posterior section of vault of pharynx 173 

92. Powder-insufflator for self-use 177 

93. Eobinson's forceps for removing hypertrophied tissue 197 

94. Smith's canula for applying caustics to the turbinated bones 197 

95. Probe for applying acetic acid to the turbinated bones . 200 

96. The author's galvano-cautery instmments 202 

97. Lincoln's electrode for the vault of the pharynx ..,*.... 203 

98. Shurley's nasal speculum, with movable slide 204 

99. Hypertrophy of the inferior turbinated bones, j)osteriorly 204 

100. Jarvis's wire snare ecraseur 205 

101. Hypertrophy of the lower turbinated bone, posteriorly, with Jarvis's 

snare in i^osition for removing it 206 

102. The author's wire curette for use in glandular hyijertrophy at the 

vault of the pharynx 207 



XVI LIST OF ILLUSTEATIONS. 

3rtG. PAGE 

103. Mackenzie's curette 208 

104. Gelatinous polyiji springing from the middle turbinated bone 239 

105. The ordinary duck-bill polypus forceps 241 

106. Polypus forceps with nari'ow and tajaering blades 242 

107. Bellocq's canula 247 

108. Adams's forceps for the re-position of a deviated septum 249 

109. Adams's screw comiDressor i^lates for deviated sejitum 249 

110. Adams's ivory plugs for the nostril 249 

111. Blandin's punch for use in deviation of the septum 250 

112. CEdema of the glottis 281 

113. Buck's laryngeal scarifier 282 

114. Tobold's concealed lancet for oedema glottidis 283 

115. Club-shai)ed thickening of arytenoids in laryngeal phthisis 288 

116. Scattered ulcerations of thu-d stage of laryngeal phthisis 289 

117. Turban-shaped thickening of epiglottis and club-shai3ed thickening 

of arytenoids in laryngeal phthisis 290 

118. Destructive ulceration of the third stage of laiyngeal phthisis 290 

119. Mucous patch on upper surface of the epiglottis 299 

120. Superficial ulcer of laryngeal syjihilis on the posterior face of the 

epiglottis 308 

121. Deep ulceration of syphilis involving the epiglottis and the ventricular 

band 312 

122. Schroetter's laryngeal dilator in situ 320 

123. Schroetter's modified laryngeal dilator 321 

,124. Mackenzie's laryngeal dilator 321 

125. Na\T.'atirs laiyngeal dilator 322 

126. Whistler's ciitting laryngeal dilator 323 

127. The laryngeal nerves 325 

128. Laryngeal branches of the pneumogastric nerve 326 

129. Transverse section through the neck at lower surface of the first dor- 

sal vertebra 327 

130. Eight recurrent laryngeal jjaralysis — position of the cords in inspira- 

tion 331 

131. Eight recurrent laryngeal paralysis— position of the cords in phona- 

tion 331 

132. Cadaveric position of vocal cords, showing the position they would 

assume in double recurrent laryngeal paralysis 333 

133. Position of cords in paralysis of thyro-arytenoideus muscle 340 



LIST OF ILLUSTRATIOlSrS. Xvii 

FIG. PAGE 

134. Paralysis of arytenoideus mtiscle, sliowing triangular opening be- 

tween -the vocal processes 341 

135. Mackenzie's laryngeal electrode and necklet 343 

136. rauvel's modification of Mackenzie's laryngeal electrode 343 

137. Transverse section of the larynx 349 

138. Bilateral paralysis of the abductors — position of cords in inspiration. 351 

139. Bilateral paralysis of the abductors — position of cords in expiration. . 351 

140. Papilloma attached to the left vocal cord 367 

141. Multiple papilloma of unusual size 367 

142. Single fibroma. 367 

143. Multiple fibroma 367 

144. Cystic tumor attached to the epiglottis 368 

145. Angioma springing from the hyoid fossa 368 

146. Tobold's laryngeal forceps 371 

147. Fauvel's laryngeal forceps 371 

148. Cusco's laryngeal forceps 372 

149. Mackenzie's laryngeal forceps 372 

150. Mackenzie's laryngeal forceps in ]position 373 

151. Mackenzie's tube forceps 374 

152. Stoerck's laryngeal forceps 375 

153. Mackenzie's guarded wheel ecraseur 376 

154. Surgical anatomy of laryngo-tracheal region 386 

155. Pilcher's tracheal retractor 387 

156. Trousseau's tracheal dilators 387 

157. La Borde's tracheal dilators 387 

158. Hutchinson's tracheal dilators 388 

159. Trousseau's tracheal canula 388 

160. Ptoger's tracheal canula 388 

161. Ordinary double tracheal canula 389 

162. Durham's tracheal canula 389 

163. Pilot trocar and inner canula for Durham's tracheal canula 390 

164. Gendron's bivalve tracheal canula 391 

165. Luer's ball valve, with side removed 392 

166. Mackenzie's pocket canula, with pilot trocar inserted 392 

167. Pilot trocar of Mackenzie's pocket tracheal canula, shoM'ing scalijel 

inserted into handle of instrument 393 

168. Preparation of Howard's imi:)rovised tracheal canula from sheet of 

lead rolled round a pencil 393 



XVlll LIST OF ILLUSTRATIONS. 

^'^' PAGE 

169. Howard's impro-\ased tracheal canula 394 

170. Hank's tracheotome 396 

171. Pilot trocar for inserting the ordinary tracheal cannla 398 

172. Trendelenberg's apparatus 400 

173. Gussenbauer's artificial vocal apparatus 409 

174. Gussenbauer's artificial vocal apparatus in section 409 

175. Foulis's modification of Gussenbauer's artificial vocal apparatus 409 



INTRODUCTION. 



The discovery of instruments of precision has always been 
followed by marked progress in that branch of medicine which 
they have been designed to serve, and perhaps in no depart- 
ment has this been more striking than in that of diseases of the 
throat ; for what was, in the main, vague guesswork formerly, 
has now become exact knowledge by the aid of the laryngo- 
scope, and we may view with no little satisfaction the amount 
of genuine work, in the direction of careful clinical observation 
of diseases of the upper air-passages accomplished since Prof. 
Czermak, of Pesth, first demonstrated the practical working 
and value of this instrument in these affections. To Czermak 
is undoubtedly due the credit of placing the instrument in the 
hands of the profession, and proving it a valuable aid in the 
diagnosis and treatment of diseases of the tliroat, although 
Garcia discovered it, and Tuerck, of Vienna, first attempted to 
make clinical use of it. 

Various attempts had been made by physicians, dating 
back as far as the early part of the eighteenth century, to ex- 
mine the larynx during life by means of the small dentist's 
mirror introduced into the throat, and similar methods, but all 
without success, until in 1854 Manual Garcia, a distinguished 
singing-master of London, conceived the idea of studying the 
movements in the larynx in phonation by means of a mirror 
introduced into the fauces, and succeeded so well that he pre- 
pared and read before the Royal Society of London an ex- 
cellent description of the physiology of the voice and the 



XX INTRODUCTIOlSr. 

respiratory movements of the larynx, in a paper entitled 
"Physiological Observations on the Human Voice." Garcia 
made his observations on his own person by standing in such 
a position that the direct rays of the sun would fall upon a 
small dentist's mirror introduced into the throat, and then, b}'' 
means of a hand-mirror held before his face, he obtained a 
view of the image formed on the throat-mirror. Little atten- 
tion was paid to Garcia' s observations at the time, but in 1857 
Prof. Tuerck, of Vienna, pursuing Garcia' s method, made some 
experiments with the little mirror, but failed to attain any 
marked success in his observations, and finally abandoned 
the idea as impracticable. Subsequentlj'^, in the same year, 
Prof. Czermak, of Pesth, took up the matter where Tuerck had 
left it, and, by substituting artificial light for sunlight, and 
making use of the ophthalmoscopic mirror to reflect and con- 
dense light upon the small mirror placed in the throat, fully 
and comjoletely demonstrated the practical value of the in- 
strument. 

Mackenzie places at the head of the opening chapter of his 
work on "The Laryngoscope" this apt quotation : "Honor be- 
longs to the first suggestion of a discoverj^, if that suggestion 
was the means of setting some one to work to verify it ; but the 
world must ever look npon the last operation as the crowning 
exploit" (Bain). 

To Garcia, then, as the inventor of the laryngoscoi)e, all 
honor is due ; but equal credit is due to Czermak, who demon- 
strated its practicability and placed it in the hands of the 
profession, as a most valuable aid in the diagnosis and treat- 
ment of diseases of the upper air-passages. 



DISEASES OF THE THROAT AND lOSE. 



CHAPTEp I. 

THE USE OF THE LAEYNGOSCOPE. 

The Laryngoscope. 

The laryngoscope consists of three essential parts : 

1. The laryngeal mirror. — A small mirror attached to a 
slender rod, which being placed in the back part of the throat 
reflects light upon the parts below, and at the same time re- 
ceives back the illuminated image, 

2. The reflecting mirror. — A concave mirror which is placed 
upon the forehead of the observer, or upon a fixed apparatus, 
in such a manner as to throw a strong light upon the laryngeal 
mirror placed in the throat. 

3. The light. 

1. The laryngeal mirror is a small round mirror encased in 
a German silver case, and attached by its rim to a slender wire 
stem at an angle of 120° ; the whole measuring about 6-7 inches in 
length. They are made in sizes from i inch to IJ inch in diam- 
eter, and are numbered from 1-4, as shown in Fig. 1, actual size. 

They are made of various shapes, such as oval, square, etc., 
but the round mirror is best adapted for all purposes. In 
selecting a mirror, it is well to choose one having a clear glass, 
a narrow rim which will give the lai-gest reflecting surface to 
the smallest bulk, and a stout stem which will allow of the 
use of considerable force without bending. 

As to sizes, if but one is purchased. No. 3 is the most desir- 
able ; if two, Nos. 2 and 4 should be selected. 

2. The reelecting mirror is a concave mirror from three to 
six inches in diameter, which sliouhl have a focal distance of 
about twelve to fifteen inches. 



2 THE USE OF THE LARYNGOSCOPE. 

It is perforated in the centre to allow of the observation 
being made in exactly the line of ilhimination, as will be 




Fig. ].— 1. The laryngeal mirror: a, handle; b, stem; r. mirror. 2. Actual sizes of the round 
mirror in ordinary use. 3. Varying shaped mirrors, a, square (Czermak) ; 6, oval ; c, according to 
Bmns. (Ziemssen.) 



noticed farther on. Its object is to receive the rays of light 
and converge them upon the laryngeal mirror placed in the 

_^ fauces. It may be mounted on a liexi- 

] ^X ^ ble bar as in Tobold's apparatus to be 

(_f \\ described ; or it may be mounted on a 

band by a universal Joint and fixed 
upon the forehead. Fig. 2 represents 
Schroetters head-band. A stout band 
passes around the head and is fastened 
with a buckle. In front there is at- 
tached a thick pad which lies against 
the forehead, with two smaller pads 
below which rest upon the bridge of 
the nose. From the metal plate upon 
which the pads are constructed there 
projects in front a split socket, regulated by a screw, which 
receives a ball attached to the reflecting mirror. In this man- 




FiG. 2. — Schroetter's head-band 



THE LARYNGOSCOPE. 




Fig. 3.— Poineroy's head-band and mirror. 



ner the mirror may be held in any position or direction in 
front of either eye. 

A simpler head-band is the Pomeroy head-band shown in 
Fig. 3j constructed on 
much the same prin- 
ciple, but simpler and 



In both of these 
head-mirrors, the knob 
which is received into 
the split socket of the 
head-band projects 
from the back of the 
mirror frame ; the re- 
sult is that the whole 
weight falls upon the forehead, rendering it necessary to draw 
the band around the head quite closely. In prolonged exami- 
nations this becomes wearisome and even painful. 

I have had made for my own use a mirror, in which the knob, 
which fits into tlie split socket, is attached to the periphery of 
the mirror frame as shown in Fig. 4. The head-band is similar 

to Pomeroy' s (Fig. 3), 
but much smaller and 
lighter, and is supplied 
with a narrow elastic 
tape which binds the 
head very gently. The 
whole affair is perfect- 
ly flat, and can be easi- 
ly carried in the vest pocket. It also admits of a more uni- 
versal motion of the mirror on the head-band. In using it the 
edge of the mirror rests upon the side of the nose. 

A method of arranging the forehead-mirror, much in vogue 
among the English, is by means of a spectacle frame shown in 
Fig. 6. This makes a rather cumbrous affair, however, and one 
only adapted for office use. 

3. The light. — This may be sunlight, gas, coal oil, or the 
oxy-hydrogen light. If gas is used, the Ai-gand burner gives 
the steadier and better flame. Sunlight affords by far the best 
light, being more poAverful than gas or oil, and giving a per- 
fectly white light which does not discolor the parts to be ex- 




FiG. 4. — The author's head-band and 



THE USE OF THE LAKYNGOSCOPE. 




aminecl, gas and oil alwa3^s giving a deeper red color to the 
mucous membrane which it illuminates, than normall}^ belongs 
to it. Sunlight should always be used, therefore, for an ex- 
amination when it is feasible. 

For its simplicity, and from ij;s being always attainable, the 
German student lamp with coal oil will be most generally 

used, the coal oil giving a 
clear, bright, almost white 
light. 

For office use, various 
instruments have been de- 
vised for modifying and 
improving the light, but 
with questionable success. 
The oldest and most prom- 
inent of these is Tobold's 
Laryngoscojje, shown in 
Fig. 9. It consists of a 
metal cylinder containing 
at its proximal end two 
double convex lenses, with 
a single lense of larger di- 
ameter at the distal end, the cylinder being attached to a hood 
which fits over the flame of the student lamp, and is attached 
by a rod to the standard. To the standard is also attached 
a jointed and movable arm which supports the reflecting mir- 
ror at its distal end, in such a manner, that it may be placed 
at any angle in front of the lens and reflect the light in any 
desired direction. What optical principle is employed in the 
arrangement of the lenses of Tobold's apparatus I have never 
been able to determine. 

Dr. Sass, of New York, has modified this apparatus by com- 
bining two plano-convex lenses in a cylinder, in a somewhat 
similar manner, the plain surfaces of the lenses presenting to 
the light, the reflecting mirror being supported in a manner 
similar to the original Tobold's apparatus, by a flexible bar in 
front of the lens. Sass's apparatus, Fig. 6, gives a very power- 
ful and beautiful light, the main objection, however, to this 
laryngoscope is its high cost. 

A simpler apparatus still is Mackenzie's Light Condenser, 
shown in Fig. 7 ; it consists in a simple hood of metal, so 



Fig. 5.— Head-mirror attached to a spectacle frame. 
At the back of the head-mirror (R) is a small cup into 
which a ball, connected with the spectacle frame, fits. A 
ring Is screwed over the ball, and the joint is thus formed 
at J. (Mackenzie.) 



THE LAEYNGOSCOPE. 



arranged that it may be fitted to any liglit, a gas jet, a coal-oil 
lamp, or even a candlestick. At the side of the hood and oppo- 




Pig. 6. — Sass's laryngoscope combined with a receiver for oompressei 



site the flame is a fenestrum into which is fitted a plano-convex 
lens 2^ inches in diameter, and comprising about one-third of a 
sphere. This may be used as a fixed apparatus by attaching 




Fig. 7. — ilaukunzies light condenser mounted upon the rack movement flxturo. 

the flexible bar to the hood and mounting the reflecting miri'or 
upon it ; or it may be used in connection with the forehead- 
mirror. (See Fig. 8.) 



6 



THE USE OF THE LARYNGOSCOPE. 



In the same plate (Fig. 7) is shown Mackenzie's rack move- 
ment fixture for gas, which admits of both lateral and horizon- 
tal movement, thus adding very much to the convenience of 




^■^^ 



Fig. 8. — Examination by niuau 



-mirror and Mackenzie" i 



coiiaeiiser, (Mackenzie.) 



an examination. To this fixture may be attached the Tobold 
apparatus, or it may be used with the forehead-mirror, using 
the Mackenzie condenser. Fig. 8, or even the simple gas jet. 

Examination of the Laetnx. 



If a fixed apparatus such as Tobold' s is to be used in mak- 
ing a larj^ngeal examination, the patient should be seated with 
the lamp on his right side, and on a level with his mouth ; the 
cylinder of the laryngoscope being directed toward the observer. 
The reflecting mirror should then be so placed as to reflect the 



EXAMmATION OF THE LARYN-X. 7 

illuminating rays toward the patient, and in such a manner 
that they form a disk of light, of which the base of the uvula 
is the centre, the head being thrown well back and the mouth 
open. (See Fig. 9.) The tongue should then be seized between 
the thumb and forefinger of the left hand, a napkin being in- 
terposed to prevent its slipping from the grasp, and drawn 
gently forward ; care being taken not to draw too forcibly. If 
preferred, the patient may hold the tongue himself. The ob- 
server should then place his right eye to the opening in the 
reflecting mirror, the left eye looking beyond its edge. The 




Fig. 9. — Examination by means of Tobold's laryngoscops, mounted on the orJinary student's lamp. 



habit should be acquired from the first of holding the face 
squarely toward the patient and keeping both eyes open, and 
also of making the observation through the opening in the 
mirror rather than from one side ; for it is in this manner alone 
that the most perfect view of the parts is obtained as will be 
noticed farther on. 

In making an examination with the forehead-mirror, the 
patient should be placed in the same position, with the light on 
his right side and at the level of his mouth. The observer 
should then arrange the mirror in such a position that it will 
reflect a disk of light upon the mouth of the patient as before 
described, while at tlie same time he can see with perfect ease, 
looking with the right eye through the perforation in the 



8 THE USE OF THE LARYNGOSCOPE. 

mirror, and with tlie left eye bej^ond its rim. (See Fig. 10.) It 
is oftentimes difficult for the beginner to get accustomed to 
arranging his head-mirror properly ; but a little practice will 
enable him to overcome this first awkwardness. The opening 
should be placed immediately in front of the eye, in such a 
way that the patient's mouth can be seen without effort 
through the perforation in the mirror ; then, without disturb- 
ing this position, the mirror can be turned until the light is 
concentrated in the proper direction. 

In using the forehead-mirror the head of the observer must 
be held in a fixed and steady position, of course, while making 
an examination. The same is also true of the patient. Tlie 




Fig. 10. — Examination \mli iln In .nl 'iiirrnr In the use of an ordinary gas-jet. 

disposition of the patient to move about and thus escape from 
the line of illumination, may be controlled by this simple 
device : while the tongue is held between the thumb and fore- 
finger of the left hand, pass the other fingers under the chin 
and press upward against the bone, while at the same time the 
forefinger rests upon the lip or gum. In this manner the jaw 
may be held with considerable steadiness and the head of the 
patient prevented from moving out of the line of vision. 

It is well for the beginner in laryngoscopy to practise some- 



EXAMINATIOlSr OF THE LAEYJSTX. 



what in the management of his light before proceeding to intro- 
duce the throat-mirror, and especially with the nse of the fore- 
head-mirror, for the advantages of using it over that of the 
fixed apparatus cannot be overestimated. While the fixed 
apparatus is only adapted for office use, the head-mirror with 
the throat-mirror forming a complete laryngoscope, may be 
easily carried in the pocket, and with the aid of a tallow candle, 
if nothing better is at hand, a very satisfactory examination 
can be made wherever it may be needed ; and this, too, with- 
out regard to the piosition of the patient, whether lying or 
sitting. 

The light having been property arranged the next step is 
to introduce the laryngeal mirror. This should be held easily 
and gently in the hand, as one 
would hold a 2Den. (See Fig. 11.) 

The mirror should be warm- 
ed over the light to prevent the 
moisture of the breath from con- 
densing upon it, and touched 
to the cheek or hand to test its 
temperature, and to prevent 
its being introduced while too 
hot. Then with its reflecting 
surface downward and parallel 
with the dorsum of the tongue, 
and the shaft held away from 
the median line in such a posi- 
tion tliat it will strike the an- 
gle of the mouth, it should be 
passed back until its edge touches the soft palate. It should 
then be passed downward and backward until the uvula rests 
on its posterior surface, when, without changing its inclina- 
tion, it should be carried upward and backward, carrying the 
uvula and soft palate with it, until it rests firmly against the 
wall of the pharynx. This is well illustrated in Fig 12. At 
the same time the patient should sound a high pitched and 
prolonged " a/*^ " ; in tliis manner the laryngeal cavity is brought 
thoroughly into view. By sounding a high note the larynx is 
lifted by muscular contraction, brought into play by the effort, 
and thereby the epiglottis is raised and uncovers the laryngeal 
cavity and allows of a freer inspection. It is often directed 




Fig. 11. 
'nzie.) 



-Holding the laryngeal mirror. (Mao- 



10 

that 
tion 



THE USE OF THE LARYNGOSCOPE. 



E'' or "A" shall be sounded in making the examina- 
many patients in the utterance of these sounds arch their 
tongues up to such an extent as to completely cut off the view ; 
this does not occur in the utterance of " a/i." In pressing the 
mirror against the pharynx it is better to press with a firm 




Fig. 19.— The laryngeal mirror in position (Cohen). This plate has been reversed by the wood-cutter, 
thus showing the mirror held in the left hand. 

hand, as there is less danger of causing retching in this man- 
ner than if the mirror is held away from the pharynx, and un- 
steadily. 

By reference to Fig 13, the relative position of the parts 
and the position in which the mirror should be held will be 
easily understood. The larynx being somewhat in front of the 



EXAMINATION OF THE LAKTNX. 



11 




Fig. 13. — The course taken by the rays of Hfjht in a laryngeal exnminM 



a, flame : 6, reflecting 



mirror, c, eye ; d, apparent and projected image of the flame ; e, laryngeal mirror; /, glottis with the 
rays of light reflected upon it by the mirror in the fauces. (Ziemssen.) 



12 THE USE OB' THE LARYNGOSCOPE. 

wall of the pharynx, the surface of the mirror must needs be 
turned at an angle with the line of vision of something beyond 
45°. The same diagram also illustrates the course of the illu- 
minating and visual rays. Commencing at the light a, the rays 
successively fall upon the reflecting mirror b, then on the hand- 
mirror (5, and are finally reflected upon and illu- 
minate the laryngeal cavity at,/, whence becoming 
visual rays they travel backward through e to the 
eye at h. This also illustrates the importance of 
using the perforation in the reflecting mirror for 
making the observation, by which the illuminating 
and visual rays fall in tiie same line ; for instance, ■ 
while the illuminating ray passing through a, h, 
e, /, illuminates the point ./, were the eye placed 
beyond the edge of the reflecting mirror b, the 
visual rays would fall upon parts which would be 
found dark and unilluminated. 

Obstacles to Laryngoscopy.— There are cer- 
tain difficulties often encountered in practising 
laryngoscopy which may be briefly noticed. 

The epiglottis oftentimes so far overhangs the 
laryngeal cavity as to very seriously interfere with 
its satisfactory inspection. To overcome this dif- 
ficult}^ various forms of hooks and pincettes have 
been devised. Fig. 14 represents the epiglottic 
pincette of Von Bruns. I have never met with an 
epiglottis that tolerated the use of any of these 
instruments. On the other hand I have very rare- 
1}^ met with a case which, with a little patience, 
did not finall}^ yield a fair examination. Other 
methods failing, the throat may be irritated pur- 
posely to such an extent as to bring on retching, 
when during the act a momentary glimpse of the 
interior of the larynx may be gained. 

Abnormal irritabiUty of the throat is proba- 

FiG. 14.— Epigldt- ^ ^ 

tic pincette of Von i-)|y file most obstluate aud trying of all the diffi- 

Bruus, -^ ./ o 

culties encountered in making a laryngeal exami- 
nation. This condition is met with in all degrees of severity, 
from the slight tendency to nausea on the introduction of the 
mirror, to the violent retching excited by the mere attempt to 
seize the tongue. Various remedies have been recommended 



EXAMINATION OF THE LAEYNX. 13 

to overcome this excessive irritability, such as bromide of potas- 
sium, morphia, chloroform, ether, swallowing pellets of ice, etc. 
But in my experience internal remedies are of little avail, and 
the only method that promises any success is extreme patience 
and perseverance on the part of the observer in educating the 
patient to a tolerance of the examination. With the exercise 
of these qualities he will rarely be disappointed of full suc- 
cess in the end. Much aid, however, may be often gained by 
simply directing the patient to take short, quick, full respira- 
tions ; the cool air striking the fauces seeming to cause a slight 
local ansesthesia ; or possibly the acquired tolerance may be 
due to the mind of the patient being somewhat diverted by the 
attempt to carry out the directions. 

A thick or unruly tongue may at times interfere with the 
observation by obtruding itself or arching itself up in the line 
of vision. In these cases resource must necessarily bp had in 
the use of the tongue depressor. 

Enlarged tonsils may interfere somewhat with an exami- 
nation, in which case a smaller mirror must be used. 

Elongated uvula. — If an abnormally long uvula exists it 
may obstruct the view somewhat, but as a rale it can be man- 
aged by a quick movement in which the mirror is passed down 
into the pharynx, and catching the uvula, holds it hrmly 
against the pharyngeal wall. In making an examination it is 
well to say that the mirror should not be held in place more 
than from ten to twenty seconds, especially with patients not 
trained to tolerance of it, as much more will be accomplished by 
avoiding the wearying of the patient and exciting retching by 
too prolonged examinations. A moderate amount of studious 
practice will soon enable one to use the mirror with consider- 
able deftness. Having accomplished this the next step will be 
the study of the laryngeal image as seen by the mirror in the 
fauces. 

The Lakyngeal Image.— At the outset it is well to divest 
oneself of the usually taught idea that the image in the mirror 
is reversed, and that right is lel't, and that the top is bottom, etc. 
The reversal of the image is simply the same that takes place 
when one looks in a dressing miri-or ; and in making a laryn- 
geal examination it is no more necessary to bear in mind that 
the image is a reversed one than it is in brusliing one's hair be- 
fore a glass. 



14 



THE USE OF THE LARYNGOSCOPE. 



Anatomy teaches the general relation of the individual parts 
of the larynx to each other ; and it is well for those needing to 
refresh the memory of laryngeal anatomy, to refer to their Gray 
before commencing laryngoscopy, and having done this it will 

be unnecessary to bear in mind 
that the epiglottis is attached an- 
teriorly, or that the arytenoids are 
in the posterior portion of the or- 
gan, or that in one sitting facing 
the observer, the right vocal cord 
is on the left of the one making 
the examination. The relative 
position of the parts is well illus- 
trated in Fig. 15. It should be 
borne in mind that a diagram, as 
in the woodcut, necessarily repre- 
sents the parts in an apparently 
vertical plane ; hence in the figure 
the image is reversed, whereas the 
relative position of the parts in 
the actual examination is some- 
thing more on a horizontal plane. 
Having brought the larynx 
into view, the first object that 
will be noticed is the epiglottis 
standing iip prominently in the upper portion of the mirror. 
It is of a pinkish yellow color, the cartilage showing through 
the mucous membrane in some parts more distinctly than in 
others.; its crest or upper border is of a somewhat crescentic 
shape, more or less curved upon itself, and presenting a great 
variety of shapes in different individuals (See Figs. 16-21), and 
is seen in varying positions, from a fully erect one, to one in 
wliich it overhangs and almost conceals the laryngeal cavity. 
If the anterior or lingual surface? of the epiglottis is brouglit 
into view, there will be noticed three folds of membrane pass- 
ing from the epiglottis to the base of the tongue, one in the 
median line and one on either side, dividing the depression, 
between the epiglottis and the base of the tongue, into two 
fossae, the lingual fossae, or glosso-epiglottic fossae. These 
fossae occasionally afford lodgment for particles of food and 
other substances, and sljould alwaj's be examined in searching 
for foreign bodies in the throat. 




Fkt. 15 — Belative position of the larynx 
and the image in the mirror. (Cohen. ) 



EXAMINATION OF THE LARYNX. 



15 



On the posterior or laryngeal face of the epiglottis, about its 
centre, there will be seen a rounded pad-like prominence of a 
deep red color, called the cushion of the epiglottis. This is 
composed of a collection of acinous glands, and is said to 




V- 



16. — Arched epiglot- 
tis. (Cohen.) 



^|V_ 



Fig. ]7. — Indented epi- 
glottis. (Cohen.) 



Fig. 18. — Asymmetrical 
epiglottis. (Cohen. ) 






Fig. 19. — Overhanging epi- 
glottis. (Cohen.) 



Fig. 20. — Omega-shaped 
epiglottis, (Cohen.) 



Fig. 21.— i'ointed and 
depressed epiglot- 
tis. (Cohen.) 



Fig. 16 represents the average normal appearance of the epiglottis, bri.ad and cre=centic in outline. 
Fig. IT is of much the same general shape with the upper border somewhat indented. Fig. 18 shows a de- 
parture from the ordinary shape, perfectly consistent with health, in which one side appears cut off. Fig. 
19 is much the same as Fig. IH, but in a position overhanging the laryngeal cavity, thus showing more of 
it.s anterior sui-face. Fig. 20 shows the cartilage markedly curved upon itstlf , the two edges being crowded 
together as it were. Fig. 21 shows a pointed and overhanging epiglottis, such as is usually seen m chil- 
dren. 

serve in a manner as a cushion for the epiglottis when it closes 
down upon the larynx. 

There will next be noticed two folds of membrane passing 
downward and backward, one from each side of the epiglottis, 
to the ar3^tenoid cartilages, two small, rounded, knob-like promi- 
nences in the lower part of the image which are seen moving 
from a state of close approximation to one of wide separation 
in the acts of respiration and phonation. These folds of mem- 
brane are the aryteno-epiglottic folds, or, as they are usually 
called, the ary-epiglottic folds, and form the lateral walls of the 
lai-yngeal cavity, separating it on either side from the pyri- 
form sinuses. At the commencement of the lower third of each 
fold will be noticed a small knob-like projection which is 
formed by the cartilage of Wrisberg, and farther down the car- 
tilage of Santorini, which, lying upon the arytenoid cartilage, 
simply serves to render it slightly more prominent, and as a 
rule cannot be distinguished from it. Passing from one ary- 
tenoid to the other, and showing a slight depression or notch 
between them, especially noticeable when they are in approxi- 
mation, will be seen a fold of membrane, the arytenoid com- 



16 THE USE OF THE LARYNGOSCOPE. 

missure, which completes the circuit of the lumen of the 
larynx, as follows : the epiglottis in front, the ary-epiglottic 
folds, showing the cartilages of Wrisberg and Santorini, forming 
the lateral wall, and the arytenoid cartilages and commissure 
posteriorly. Immediately behind the commissure will be no- 
ticed a closed fissure between it and the wall of the pharynx, 
which is the orifice of the oesophagus. Going back now to the 
ary-epiglottic fold, there will be noticed on the outer side of 
each a somewhat pyramidal-shaped cavity, the pyriform sinu- 
ses. These are bounded by the thyroid cartilages externally, the 
ary-epiglottic folds internally, and the pharyngeal wall poste- 
riorly, where they approximate one to the other, and pass 
down into the oesophagus, behind the arj^tenoids. At the bot- . 
tom of each sinus may be seen the superior cornua of the hyoid 
bone. These cavities form exceedingly favorable sites for the 
lodgment of fish-bones, particles of food, or other substances, 
and should' always be carefully searched in looking for foreign 
bodies. 

Coming now to the interior of the larynx ; passing from 
above downward, the first objects noticed are the two false 
cords, more properly called the ventricular bands. These are 
two folds of membrane, one on either side, passing from the 
receding angle of the thyroid cartilage anteriorly, where they 
are nearly in apposition, to the arytenoid cartilages posteriori 3^ 
They are of a rather deeper red color than the other portion of 
the laryngeal cavity ; they move with the arytenoids, and are 
parallel with the vocal cords, being separated from them by 
the openings of the ventricles of the larynx, which lie imme- 
diately below them and can be but imperfectly seen. The 
trae vocal cords are next seen, two white glistening bands mov- 
ing back and forth with the acts of phonation and respiration. 
Their color is due to the fibrous tissue of which they are com- 
posed, showing through the mucous membrane which covers 
them, and which is extremely thin, and endowed with a very 
sparse network of blood-vessels. During the acts of inspi- 
ration the cords are widely separated, and a view is obtained 
of the parts below. The position of the mirror being, as a rule, 
behind the axis of the trachea, it is the anterior wall that is 
seen, showing its rings surmounted by the cricoid cartilage. In 
very favorable cases a view of the bifurcation of the trachea 
may be obtained. 



EXAMINATIOIST OF THE LARYNX. 



17 



The general appearances of the healthy larynx with the col- 
oration of the healthy mncous membrane require no lengthy 
description. It may be determined by the same tests to which 
any mucous membrane is subjected which can be seen by direct 
ocular inspection. In general it may be said that the lining 
membrane of the lar^mx is of a rose-pink color, with a tendency 
to yellow, especially where the cartilages are seen through on 
the surface, as at the crest of the epiglottis and on its sides, the 
eminences made by the cartilages of Wrisberg and Santorini, 
the inner wall of the trachea where the rings are manifest, etc. 
In all these places the membrane is of a light yellowish pink 




Fig. 22.— The laryngoscopic image, double size, the glottis being open as during inspiration. (Heitz- 
mann.) 



color. Again, where the membrane covers a mass of glands, 
or adipose, or loose connective tissue, it is of a deeper red 
color. This is shown in the cushion of the epiglottis, the ary- 
epiglottic folds, the arytenoid commissure, and the ventricular 
bands. 

A reference to Fig. 10 Avill show the relative position of the 
parts with the names attaclied ; the rima-glottidis being open, 
and the cords being in the position wliicli they assume during 
the act ol' inspiration. Fig. 11 shows a smaller view of the lar- 
yngoscopic image, the cords being approximated for phona- 
tion. In the absence of a larynx from the cadaver or a good 
model, it will be found not a bad ])lan to use this figure for 
(examination with the mirror. The l^ook being held with the 



18 



THE USE OF THE LARYNGOSCOPE. 




upper border of the plate toward the observer, but in such a 
manner that it cannot be seen b}^ direct vision, place the laryn- 
o-eal mirror in such a position as will give a reflected view of it ; 

it will afford a fair idea of the part 
seen in making an observation in 
the living subject. 

In making an examination the 
first thing to notice is the general 
appearance of the mucous mem- 
brane. Is it discolored in any 
way, or does it show evidences of 
any of the forms of intlammatory 
troubles \ Then notice the conformation of the larynx, the ex- 
istence of growths or tumors, or is there loss of tissue from 
ulcerative or any destructive process ; and, finally, as to move- 
ment, notice if there maj^ be any deviation in the normal move- 
ment of phonation or respiration ; are the cords approximated 
in the median line perfectl}^ and do thej^ show a perfectly 
straight edge ; are they properly abducted, and are the move- 
ments perfectly symmetrical ? 



Fig. 23.— The Juruiguscnpic image, the 
glottis being closed as during phonation. 
(Ziemssen.) 



Examination of the Phakynx. 



It would seem as though this were so simple a manipulation 
as to require no especial directions, yet oftentimes a beginner 
attem^^ting to examine an obstinate patient will meet with diffi- 
culties which might easily be overcome by following very sim- 
ple directions. 

This examination is generally made without the aid of any- 
thing more than ordinar}^ direct light, a lamp being held before 
the mouth, or the patient being directed to stand with his face to 
the window. Whether daylight or artificial light is used, I re- 
gard the retiecting mirror of the greatest imj^ortance, and indeed 
am accustomed to carry one in vi\j pocket at all times, and 
make almost invariable use of it in examining the pharynx. It 
condenses so strong a light upon the parts, with nothing to in- 
tervene and obstruct the direct inspection, as is the case when a 
candle is used, or daylight in the ordinarj" method, that it is a 
very simple and eas}^ matter to search the whole fauces, and 
be thoroughly satisfied as to the existence or non-existence of 



EXAMINATION OF THE PHARYNX. 



19 



morbid conditions wliich otherwise might easily escape notice ; 
such as small diphtheritic or croupous deposits, enlarged or 
inflamed follicles, mucous patches, etc. 

Many persons can easily depress their own tongues in so 





Fig. 24. — Tuerck's tongue spatula. 



PtG. 25.— Pocket folding spatiili 




IT. S. A. spatula. ri 



satisfactory a manner as to afford a complete view of the fauces, 
but in a majority of cases a tongue depressor or spatula will be 
necessary. Fig. 24 represents what is generally known as 
Tuerck's spatula. It is an excellent instrument and can easily 
be held by the patient himself; although, unless he has had 



20 



THE USE OF THE LAEYNGOSCOPE. 



some training, the physician will be compelled to introduce the 
instrument. Fig. 25 shows a much simpler instrument, an 
ordinary pocket folding spatula, which answers an excellent 
purpose. 

There is no better instrument devised than the ordinary U. S. 
army spatula, Fig. 26 ; this, however, is a somewhat rudely 
made instrument. Sass's spatula, shown in Fig. 27, is con- 
structed on the same principle. 

Fig. 28 illustrates in much reduced size a very simple spat- 
ula, suggested by Dr. Sexton, equally adapted for the tongue 





Fig. 27.— Sass's spatula. 




Pio. 28. - Sexton's spatnla. 



and the cheeks when it is desired to explore the mucous mem- 
brane of the oral cavity. 

In introducing the tongue depressor, its beak should always 
be carried beyond the arch of the tongue, that is, beyond the 
highest point to which the tongue is visible, otherwise in press- 
ing it downward its anterior end only will be depressed, while 
its centre will arch up and interfere with the inspection. This 
may seem a very simple and even unnecessary direction, but I 
have had to repeat it so often to my students, manj'- of them 
physicians of long practice, that it will not seem out of place to 
repeat it here. The beak of the spatula should be carried just 
far enough to cover the arch of the tongue and no farther, 



EXAMINATION OF THE PHARYNX. 



21 



otherwise its pressure on the sensitive parts near the base of 
the tongue will be liable to excite retching or vomiting. 

The spatula should be held between the thumb and forefin- 
ger, the thumb pressing against the angle while the second 
finger passes under the chin ; in this manner a grasp is ob- 
tained of the lower jaw, and control of the movement of the 
head secured. Then the tongue should be pressed, not down- 
ward, but downward and forward, by a rotary movement of 




Fig. 29.— Method of introduoin?: the spatula and depressing the'tongue. 



the spatula, the beak of the instrument being made to revolve 
in tlie arc of a circle which has its centre at the teeth. If this 
movement is made with a slow but firm pressure, the whole 
fauces will be brought into view, and in a small propoi'tion of 
cases the epiglottis even, will be seen rising up at the base of 
the tongue. If retching occurs, however, before the inspection- 
is accomplished, the attempt should immediately be aban- 
doned for the time, and a few moments of rest given. In all 
cases a view shoiild be gained of the parts fully at rest, as the 



22 THE USE OF THE LAEYNGOSCOPE. 

instant retching occurs the contraction of the palato-glossus 
and palato-pharyngeus muscles forces the tonsils so far into 
the median line as to prevent the observer forming any esti- 
mate as to the true condition ; and also so far masks the pharyn- 
geal wall as to prevent its proper inspection ; the palate and 
uvula are also elevated to such an extent that their surface can 
not be properly examined. A reference to Fig. 29 will show 
the position of the spatula, the method of grasping it, the 
movement by which the tongue is depressed, and the direction 
which it takes. The parts seen on pharyngeal examination 
need no explanation ; they comprise simply the pillars of the 
fauces, with the tonsils lying between, the uvula and soft 
palate, and the pharyngeal wall. 

The examination in the main is to determine the existence 
of croupous or diphtheritic deposits, any of the varieties of 
catarrhal inflammation, or follicular engorgement, the existence 
of mucous patches, ulceration, enlargement of the tonsils, elon- 
gation of the uvula, the existence of tumors or any morbid 
growths, paralysis of the muscles of the palate, etc. 

The difiiculties encountered in making an examination of 
the pharynx are all embraced in the one condition of excessive 
)rritabilit3\ which can only be surmounted by patience and 
persistent effort on the part of both the physician and patient. 



Examination of the Nasal Cavity. 

This examination is made both anteriorly and posteriorly, 
and in order that it may be made with any degree of satisfac- 
tion, the reflecting mirror is absolutely necessary. 

The examination anteriorly is made by dilating the flexible 
portion of the nostrils by some suitable speculum, and throw- 
ing the light in by the mirror, so held that the focus of light 
may fall upon the part to be examined, the tip of the nose be- 
ing lifted by the thumb of the left hand. The head of the 
patient should be thrown well back and then brought gradu- 
ally^ forward in order to bring into view the different parts suc- 
cessively. An ordinary ear speculum of large size answers the 
jxurpose very well, but it requires the use of one hand to hold 
it, and also simply holds the nostrils open without dilating 
them. 



EXAMINATION OF THE NASAL CAVITY. 



23 



Fraenkel's speculum, shown in Fig. 30, is composed of two 
blades regulated by a set screw. It may be inserted in both nos- 
trils, or one, at pleasure, and serves to dilate the opening. It is 
also self-retaining to an extent. Goodwillie's speculum. Fig. 31, 





culum. Fia. 31. — G-oodwillie's nasal speculum. 

a much simpler and cheaper instrument than Fraenkel' s, has 
three blades, which spread by their own elasticity and answer 
quite as good a purpose. An ordinary hair-pin, with a half 
inch of the bowed end bent at right angles, makes a most excel- 
lent speculum, and is within reach of every one. The method 
of using it is shown in Fio-. 32. 




Fig. 32. —Examination of nasal cavity anteriorly, by means of a bent hairpin. (Cohen.) 

Fig. 33 shows a simple nasal speculum which I have had 
constructed for my owu use, and which is more perfectly self- 
sustaining than any other within my knowledge. It is simple 
and inexpensive. 

Fig. 34 illustrates Simrock's speculum. This is an excellent 
instrument, and especially adapted for use in making caustic 



24 



THE USE OF THE LARYNGOSCOPE. 



applications, where it is necessary to protect the nostril from 
accidental contact with the agent used. 

Elsberg's trivalve nasal speculum is showm in Fig. 35, and is 
• a very efficient instrument. 

It should be remembered in regard to the use of the nasal 
speculum that it is in no wise designed to separate the cartila- 
ginous alee of the nose, but merely to distend the flexible por- 
tion of the nostril, hence it should never be introduced beyond 
that portion of the nose. 

The 'parts seen. — With the head bent forward, and the tip 
of the nose lifted, there will be brought under inspection a con- 
siderable portion of the floor of the nares, with the anterior 



Fig. 34. — Simrock's nasal speculum. 




Fig. 35.— Elsberg's nasal speculum. 



termination of the inferior turbinated bone, a pale red rounded 
protuberance, projecting from the outer wall of the cavity; also 
the wall of the septum for a considerable distance. Occasion- 
ally, if the cavity is wide and a strong light is used, there can 
be seen, through the fissure between the turbinated bone and 
the septum, the wall of the pharynx. As the head is thrown 
backward there is brought into view^ the under surface and an- 
terior termination of the middle turbinated bone, lying appa- 
rently somewhat behind the inferior bone ; and finally, a small 
portion of the roof of the nares, with the whole anterior nasal 
cavity, and the remaining portion of the septum as high as the 
superior turbinated bone. If the examination is in any way 
interfered with by the hairs which lie in the nostril, they can 
of course easily be removed by the scissors. 



EXAMINATION OF THE NASAL CAVITY. 25 

The anterior examination reveals the condition of the mu- 
cous membrane of the nose, as far as seen, as to the character 
and degree of inflammation existing ; the amount and charac- 
ter of its secretion ; the existence of ulceration and necrosis ; 
the degree to which the passage is pervious ; the position of the 
septum as regards its deviation from the median line ; and fin- 
ally, the existence of any neoplasm in the cavity, by far the 
most frequent of these being mucous polypi. 

It is especially urged in this connection, that, whenever it 
is possible, sunlight should be used in preference to the artifi- 
cial light. By this means it will often be feasible to explore 
the whole nasal cavity from in front, and even bring into view 
the wall of the pharynx. 

The examination posteriorly is made by so placing the 
small laryngeal mirror in the back part of the fauces that it 
will give a reflected view of the parts above and out of the 
line of direct vision. The patient should be placed in the same 
position as that required for examination of the larynx, and 
the light thrown into the open mouth in such a manner that 
the rays are brought to a focus at or near the wall of the pha- 
rynx. 

The next step is so to depress the tongue that ample space 
will be afforded between its base and the free border of the soft 
palate for the passage of the mirror without its touching the 
parts. For depressing the tongue the same remarks appl}^ as 
were made in reference to the examination of the pharynx. 
In order to obtain a successful observation it is absolutely ne- 
cessary that the throat should be completely relaxed, and es- 
pecially that the palate should be entirely at rest and hang- 
free from the pharynx, as it is through the opening between 
these parts that the view is obtained. If the mirror on its in- 
troduction touches the uvula, soft palate, or the root of the 
tongue, it is extremely liable to cause so much irritation, for 
these parts are very sensitive in most patients, that contrac- 
tion of the faucial muscles will occur, and the palato-pharyn- 
geal opening be completely closed, and of course the examina- 
tion prevented. 

Having then the tongue thoroughly depressed, while at the 
same time the faucial muscles are completely'' relaxed, it will be 
seen that there is a wide space afforded behind the soft palate 
and uvula for the introduction of the mirror. It may be here 



26 



THE USE OF THE LARYNGOSCOPE. 



remarked that until this space is seen to be open, and the parts 
are entirely relaxed, the attempt should never be made to pass 
the mirror, but the patient should be subjected to such train- 
ing as will enable the observer to depress the tongue without 
exciting those muscular contractions which shut off the palato- 
pharyngeal opening. As a rule, this may be easily accom- 
plished by the exercise of a little patience for a few moments. 

The next step is to introduce tlie mirror. This should be 
held lightl}- in the hand (See Fig. 36), and passed back some- 




FiG. 36. — Holding the mirror for ihe rhinoscopic examination. The angle between the mirror and the 
shaft is such as is adapted for examining the vault of the pharynx. (Browne.) 

what edgewise in order that it may pass through the notch be- 
tween the uvula and right pillar of the fauces, if the mirror is 
held in the right hand, in such a manner that it may not touch 
the parts, there not being, as a rule, sufficient room for it to 
pass under the uvula. Then by twisting the handle from left 
to right between the fingers, the reflecting surface should be 
brought around so that it will receive the raj^s of light in a 
direct line, and the mirror carried upward until its ujDper bor- 
der is slightly hidden by the soft palate. 

If the patient is directed to sound, with as full a nasal twang 



EXAMINATION OF THE NASAL CAVITY. 



27 



as lie can give it, "gi^," it will aid very mucli tlie success of 
the manipulation, for thereby the palate is lowered and the 
palato-pharyngeal space thrown widely open. 

The position of the mirror should be at a right angle with 
the line of vision, and nearly in a vertical plane ; the handle 
being held at one side as in larjaigoscopy, with the shaft lying 
against the corner of the mouth. A reference to Fig, 37 will 




Fig. 37. — The mirror in position for makinp; a rliinoscopic examination, with the parts seen. 



illusti-ate the position of the mirror and the relative position of 
the parts brought into view by tlie manipulation. In tlie lower 
portion of the mirror there will be ^een reflected tlie posterior 
surface of the uvula and soft palate, while in the upper portion, 
the roof of the pharynx will be seen where it passes into the 
nasal fossae. Beyond these, and in the dim background, as it 
were, there will be brought under inspection a somewhat fore- 



28 THE USE OF THE LARYNGOSCOPE. 

shortened image of the nasal foss?e, with the turbinated bones, 
the septum, and the orifices of the Eustachian tubes. 

As a rule, a smaller mirror is used in rhinoscopy than in 
laryngoscopy, a No. 2 or 3 being the usual size. It should also 
be bent at a sharper angle with the shaft, the angle being 
about 100°— 110°. 

Obstacles to Rhinoscopy.— The main obstacle to the exami- 
nation is an irritable throat, as in laryngoscopy, with the only 
difference that it is less easily surmounted. For its management 
the same remark may be made as was made concerning the lar- 
yngeal examination ; the greatest patience must be exercised 
in teaching the patient to relax his throat, and allow of the in- 
troduction of the mirror without gagging. As a rule, this is 
only accomplished by the persistent, but patient, slow and 
gentle introduction of the spatula and mirror, carrying the 




Fig. 38 — Diiplay's rhinoscope. 



operation to the point of tolerance, but arresting it always be- 
fore retching is excited. 

A71 ohstinate tongue which arches itself up in the mouth, 
and cuts off the view, often accompanies an over-sensitive 
throat, and is overcome by a similar exercise of patience. 

Enlarged tonsils, if sufficient to interfere with an inspec- 
tion, should be removed. 

A narroio palato-pliaryngeal space is sometimes a trouble- 
some obstacle in rhinoscopy, as it affords but scant room for 
the examination. In order to overcome this difficulty, various 
hooks, dilators, and retractors have been devised. A simple 
rounded hook may be passed around the palate for drawing 
it forward, but it requires the use of one hand, and is also not 
usually well tolerated by the patient. Fig. 88 represents 
Duplay's rhinoscope, wdiich is designed to overcome this diffi- 
culty somewhat. None of these devices, however, are of much 
service, as the palate is so sensitive that even when an exami- 



EXAMINATION OF THE NASAL CAVITY. 29 

nation may be easily submitted to, the impact of instruments 
of this kind is not tolerated. For the examination alone a little 
training of the patient will usually enable the observer to ac- 
complish all that he desires. Where it becomes necessary to 
make a more careful examination, or where the success of an 
application or operation requires the absolute control of the 
palate, or a wider patency of the palato-pharyngeal space, the 
resort can always be had to the method of tying the palate sug- 
gested by Dr. Wales of the United States ]N"avy. This procedure 
consists in passing a cord through each nostril to the pharynx, 
and drawing it out through the mouth, when it is passed over 
the ear on each side and tied behind the head. By this means 
a gentle traction can be exercised on the palate, under which it 
gradually yields, and is finally folded on itself, as it were, and a 
broad space afforded for reaching the parts above for manipula- 
tion or operation. This device of Dr. Wales is very simple, easily 
accomplished, and well tolerated by the patient, and should 
always be resorted to in any case in which it will add to the 
completeness of the diagnosis or promote success in operating. 

The passing of the coi'ds through the nares maybe done by 
the Bellocq canala (Fig. 107), but the objection to this instru- 
ment is, that it is so large that it may cause unnecessary pain, 
and also troublesome hemorrhage. 

Dr. Duncan recommends the use of a small, flexible male 
catheter, with the stylet in place, for passing the cords ; and it 
is an excellent and use- 
ful device. By sliiDping 
a cord under the stylet, 
through the fenestrum 
at the end of the cath- 
eter, it can easily be carried to the pharynx, when by with- 
drawing the wire the cord is released, and being seized by a 
long pair of forceps it can be drawn out through the mouth, 
while the catheter is withdrawn from the nose. 

I have had constructed a serviceable little instrument, 
shown in Fig. 39, for the purpose of passing the cord through 
the nares, suggested by the Bellocq canula. 

An ordinary Eustachian catheter of hard rubber is short- 
ened to about four inches, and bent to adapt it somewhat to the 
floor of the nares, as shown in the figure. This little canula 
can be passed easily and painlessly through the nares, and 




30 THE USE OF THE LARYNGOSCOPE. 

when ill position lies upon the floor of the cavity, with its 
curved extremity slightly projecting over the soft palate and 
directed downward into the pharynx, while the expanded por- 
tion protrudes slightly from the nostril. ' A stiff piece of linen 
cord is now passed through the canula until it emerges into the 
pharynx, when it is easily seized with a pair of forceps and 
drawn out through the mouth, while at the same time the 
canula is withdrawn from the nostril. The cord is then tied in 
front of the lip and the same procedure repeated for the other 
nostril. The ordinar}^ surgeon's knot of three turns should be 
used in tying the cords, as in this manner they can be quick- 
ly and easily released or drawn up as may be desired. I usu- 
ally keep a supplj^ on hand of cord which has been immersed 
slightly in mucilage and allowed to dry, as this gives it a firm- 
ness and stiffness which renders its passage through the tube 
very much easier. Catgut answers a most excellent purpose in 
place of the linen cord, in that, when moistened with the mucus 
of the parts, it is less irritating than the linen is liable to be. 

When the cord is drawn out through the mouth it should 
be tied as quickl}^ as possible, as the tension on the palate is 
far better tolerated than the loose cord dangling in the fauces. 
This plan of tying the palate is quite easy of accomplishment, 
is very well borne by the patient, is not usually attended with 
any difficulties, and should always be resorted to when it will 
add in any way to the completeness of a diagnosis. In oper- 
ating or making the stronger ai^plications to the upper pharynx 
it becomes almost an indispensable aid. 

A lonr/ uvula not unfrequently proves an obstacle in mak- 
ing a rhinoscopic examination. It may be raised by means of 
a hook or pincette ; or, better still, it may be caught in an elastic 
slip- noose and drawn forward. This latter plan will be well 
tolerated, and occasionally serves a good purpose, in jDlace of 
tying the palate by means of Wales's method, to obtain access 
to the posterior nasal and pharyngeal regions for examination 
and the simpler operations. 

The Rniisroscopic Image. — The mirror being placed in the 
position described, there will be brought into view the oval- 
shaped openings of the posterior nares, Fig. 40. Separating them 
in the median line there will be seen, the septum, broad above 
and tajDering to a sharp and narrow edge below. On each side 
of the septum will be seen, as dark cavities, the nasal passages 



EXAMIlSrATIOlSr OF THE NASAL CAVITY. 



31 




Fig. 40. — The rhinoscopio image: 1, vomer, or 
nasal septum ; 2, rfasal passages ; S, superior meatus ; 
4. middle meatus ; 5. sup(3rior turbinated bone : 6, mid- 
dle turbinated bone ; 7, inferior turbinated bone ; 8, 
pharyngeal orifice of Eustachian tube ; 9, upper por- 
tion of fossa of Rosenmillier ; 31, glandular tissiie at 
the vault of the pharynx ; 12, posterior surface of the 
palate and uvula. (Cohen.) 



and projecting into tliem, from the outer wall of each, the turbi- 
nated bones. The superior turbinated bone will be just visible, 
a light reddish band, in the upper part of the image, emerging 
as it were from the shadow, and seeming to slant upward and 
forward. Immediately below it, and separated from it in the 
posterior portion by a dark 
line, the superior meatus, 
will be seen the middle tur- 
binated bone, appearing as 
an elongated and somewhat 
fusiform projection, of a yel- 
lowish red color. Below this 
again may be seen a consider- 
able portion of the middle 
meatus, and below this the 
upper half of the inferior 
turbinated bone, of much 
the same color as the middle 
bone, and giving the impres- 
sion of a somewhat elongated mass resting on the floor of the 
nares. The inferior meatus and floor of the nares cannot be 
brought into view. If now the mirror be turned somewhat to 
one side, there will be seen the eminence surrounding the orifice 

of the Eustachian tube, sepa- 
rated from the lateral wall of 
the vault of the pharynx b}^ the 
sinus of Rosenmiiller. The Eus- 
tachian tube being seen in pro- 
file, the orifice simpl}^ shows a 
dark line on a bright yellow 
background, which is the an- 
terior wall of the depression 
leading into it. 

By changing the inclination 
of the mirror now to a more 
obtuse angle (See Fig. 36), tliere 
will be brought into view the 
dome-like cavity of the vault 
of the pharynx, presenting a 
somewhat irregular outline, the surface being marked by fur- 
rows and depressions wliicli indicate the site of the pharyngeal 




Fig. 41. — 'I'll.' -huMinhn- -Uumirr (,f the 
vanlt of the pli:.i\ n-. nutiinil >\'/.,- i l.iischkn ) : 
1—1, pterygoid processes; 2, vomer: '-i—H, ijos- 
terior i)ortion of the nasal fosste ; 4, Enstiuhiiin 
tnhe; 5, bursa pharyngea; 6, fossa of lioscn- 
miillcr; 7, irregular surface of the glandular 
tissue. (Luschku.) 



32 THE USE OF THE LARYNGOSCOPE. 

tonsil (See Fig. 41) ; the parts becoming smoother as the view 
passes down, until there is seen the deep red, smooth, shining 
surface of the mucous membrane of the lower pharynx. This 
change in the inclination of the mirror is best accomplished by 
simply turning the handle in the fingers, as the attempt to ac- 
complish it by elevating or depressing the hand is liable to end 
in causing retching. To obtain a complete inspection of the 
vault of the pharynx, it will generally be found best to change 
the mirror and use one mounted at an angle of 130°, the same 
used in making a laryngeal examination. 

This examination reveals the condition of the mucous mem- 
brane of the nasal cavity ; the variety and extent of the hyper- 
trophic thickening which characterizes nasal catarrh ; the con- 
dition of the pliaryngeal tonsil ; the extent of hypertrophy 
that may exist there ; the character and amount of the secre- 
tions from tlie parts ; the existence of tumors in the nose, or 
vault ; ulceration ; necrosis, etc. 



CHAPTER IT. 

MUCOUS IVIEMBEANES.* 

Befoee entering upon the consideration of special diseases, 
a better comprehension of them will bt? obtained by devoting a 
separate chapter to the subject of mucous membranes in general. 

Anatomy. 

A mucous membrane in its construction closely resembles 
the skin, of which it ma}^ be considered a modification ; the 
one being the covering membrane of the external surface of the 
body, while the other forms the lining membrane of such in- 
ternal cavities and passages as communicate with the exter- 
nal world : these are the intestinal canal, the lungs and air- 
passages, and the genito-urinary tract ; the membrane as 
found in these parts presenting the same general type. It is 
generall}^ described as composed of two laj^ers, a basement 
membrane and an epithelial coat ; but beneath the basement 
membrane. there is found a cellular tissue which pla^^s so im- 
portant a part in its pathology that it may be properly con- 
sidered a third layer. There are then : First, a non-vascular 
layer composed of epithelial cells. Second, the mucous mem- 
brane proper, a layer composed of fibres of connective and 
elastic tissue embracing within their meshes, blood-vessels. 



* This chapter on mucous membranes was prepared, in the main, for an introduc- 
tory lecture in my course at the Bellevue Hospital Medical College several years ago. 
I insert it here with few changes, believing that a clearer understanding of the dis- 
eases of the upper air-passages will hereby be attained by such as may not be already 
familiar with the subject of the chapter. I, of course, pretend to no original research 
on the subject, as the bulk of what I have written is compiled. For much of the 
subject I am indebted to Dr. Green's admirable work on "Pathology and Morbid 
Anatomy." I prefer to acknowledge my indebtedness in this foot-note rather than 
mar the text by the numerous quotation-marks which would be neccs.sary were I to 
resort to their use. 

3 



34 



MUCOUS MEMBHANES. 



smooth muscular fibres, differeut forms of small glands, and 
presenting minute processes or villi. TJurd, an external layer 
of loose connective tissue ; the submucous cellular tissue. (See 
Fig. 42.) 

First — The e])ltlLelial layer. — An epithelial cell, the typical 
or elemental gland, is simply a soft rounded cell, containing a 
nucleus and cell contents, pellucid or granular, and all con- 




FiG. 42. — Vertical section of a mucous membrane (Luschka): a, compound or racemose gland; 6, 
simple follicle; (, villi, containing a network of blood-vessels or a single loop, with nerve-filaments; d, 
epi helial layer; e, mucous membrane proper containing blood-vessels, nerves, muscular fibres, and 
rounded and closed follicles ; /, submucous connective, or areolar tissue. 

tained in a cell-wall whose varying shape gives to it its name ; 
such as : 

1. PaDement or tesselated e\)i\\nAmm, so called from their 
being pressed down and flattened from above, and crowded 
together in such a manner as to give an angular outline to each 
cell. (Fig. 43.) 

2. Columnar eiyitlielmm. — Elongated cells with rounded or 
square ends. (Fig. 43.) 

3. Columnar ciliated epithelium. — The same shaped cell as 
the columnar, but endowed with fine hair-like processes on 
the free end, which possess the power of vibratory motion. 
(Fig. 43.) 

4. Squamous epitlielium. — Worn out or dried cells which 
are thrown off from the surface. 

These cells may be arranged in a single layer or in several 
layers, one above the other ; this latter arrangement is generally 
found in mucous membranes in two varieties. 

a.. The laminated pavement. — Commencing with theelonga- 



ANATOMY. 



35 



ted or columnar cells beneath, and becoming rounded above 
until they reach the surface where they become of the pave- 
ment variety. This arrangement is found in the lower portion 
of the pharynx, and in the oesophagus. 

h. T7ie laminated ciliary. — Commencing with rounded cells 
below, which, becoming elongated as they approach the surface, 
show on the upper layer the columnar ciliated cells. This 
variety is found in the lungs and air-passages, except the 
smaller bronchi. 

Second — The mucous membrane proper. — Beneath the epi- 
thelial cells is found the mucous membrane proper ; composed, 
as stated, of connective tissue, elastic tissue, muscular fibres. 




TESSELATED 



C0LUEV1NAR 



CILIATED 



Fig. 43.— Epithelial cells. 

glands, blood-vessels, and nerves, and marked by minute pro- 
cesses or villi. 

TJie connecthe tissue which is found in this layer is com- 
posed of fine fibrils united into bundles by a small quantity 
of a clear connecting substance, and forms a close network, 
or an almost homogeneous membrane. In tliis connective tis- 
sue we find certain cells, resembling the white corpuscles of 
the blood, the so-called leucocytes. This is the connective- 
tissue corpuscle, or, as it is sometimes called, the migrating 
corpuscle, and again the amoeboid cell, from its observed power 
of motion. This cell performs an important part in inflamma- 
tions, not only of mucous membranes but of other tissues, as 
will be noticed farther on. 



36 MUCOUS MEMBRATq-ES. 

The elastic tissue, one of the elementary structures of the 
body, is displaj^ed more or less freely throughout this layer, 
and is composed of simple thread-like fibrils, crossing and in- 
terlacing in every direction. It is of a yellow color and pos- 
sesses a high degree of elasticity. 

The muscular fibres are of the un striated variety, and are 
very sparsely distributed through the layer. 

The glands are of two varieties, the simple follicle and the 
compound follicle or racemose gland. The simple follicle is 
merely an infolding of the membrane into a straight tube or 
tiask-like cavity. The racemose gland is composed of a cluster 
of Hask-like follicles, opening into a single duct, whose orifice 
is upon the surface of the membrane. 

The vessels are very numerous and form close meshes in the 
membrane proper, sending a loop into the smaller villi, and 
into the larger, a close network. 

Third— The submucous cellular tissue. — This is composed 
of a more or less loosely connected network of connective tis- 
sue, by which the mucous membrane is attached to the parts 
beneath, and of course allows of a very free play between the 
membrane and these parts. This fact becomes of extreme im- 
portance in connection with acute inflammatory affections of 
the membrane, as it admits of the effusion of serum into this 
layer, where its attachment is verj^ loose, as in the ary-epiglottic 
folds of the larynx, the posterior surface of the epiglottis, and 
the ventricular bands. 



Physiology. 

The function of mucous membranes is to afford a soft, 
moist, and pliable lining, to those cavities and passages of the 
body, which communicate with the external world. It is lubri- 
cated by a clear fluid mucus, which is poured upon it by the 
follicular and racemose glands, whose ducts open upon its sur- 
face ; and also by the epithelial cells which compose its super- 
ficial layer, each epithelial cell being in its small way an inde- 
pendent and secreting gland. 

Groioth. — Owing to the constant mechanical disturbance to 
which the membrane is subjected in mastication, speaking, etc., 
the cells of its superficial layer are being constantly detached 



PHYSIOLOGY. 37 

and thrown off. In order to compensate for this loss, new cells 
are bemg continuously generated from below. The method by 
which this is accomplished is exceedingly simple, and may be 
explained by a very brief reference to cell pathology. Yirchow 
first advocated the doctrine some twenty years ago which now 
meets with general acceptance, that every cell grows from a 
parent cell ; and in no department of histological study is the 
observation more clearly conhrmed than in that of mucous 
membranes. The method of cell-development is probably by 
one of three processes : 

1. Division. — A constriction develops across the centre of a 
cell, which becoming narrower and of an hour-glass shape 
finally separates, and in place of one cell two cells exist. 

2. Gemmation.— Im this process there appears at some point 
in the cell- wall a small projection which protrudes more and 
more, while its attachment to the parent cell becomes narrower, 
and finally, -it drops off a newly developed cell. 

3. Endogenous growth. — A new cell is developed inside the 
parent cell, as the foetus in the mother's womb; and finally, 
when it has attained maturity, it bursts its wall and escapes. 

It is by one of these processes that new cells are being con- 
stantly generated in the deeper layer of the epithelial coat of 
the membrane, to make good the waste which is constantly go- 
ing on at its surface. 

Another physiological characteristic of mucous membranes 
is their permeability, by which fluids may penetrate them from 
without, and become absorbed by the blood-vessels, or per- 
ceived by the nerves. The activity of this function depends 
mainly on the thickness of the epithelial coat, and where this 
is very thin, as over the papillae of the lips, and the tip of the 
tongue, we find this sensitiveness very acute. 

An exception to this rule is found in the fact that the virus 
of the snake does not permeate mucous membranes, and is in 
no way absorbed by them, it being necessary that it should 
meet with an abraded or cut surface, in order to reach the 
blood-vessels and be taken up by them. Tlie same is true of 
the syphilitic virus, which is only inoculable through an abra- 
sion of the membrane. 



38 mucous membranes. 

Inflammation of Mucous Membranes. 

Inflammation is tliat series of clianges which takes place in 
any tissue as the result of an injury, provided the injury is 
not of such a character as to completely destroy its vitality. 
This injury may be a direct irritation of the tissue by a me- 
chanical or chemical agent, or by substances carried to it by 
the blood, or it may be an indirect irritation, as is the case in 
inflammation of internal organs, as the result of exposure to 
cold. 

Through the researches and experiments of Cohnheim, 
Strieker, Burdon-Sanderson, and others, the nature of these 
changes is well known. The process comprises : 

1. Changes in the blood-vessels and circulation. 

2. Exudation of liquor sanguinis and migration of white 

blood-corpuscles. 

3. Alteration in the nutrition of the inflamed tissues. 

1. The first effect of an irritation of the tissues is to cause 
dilatation of the arteries, followed soon by dilatation of the 
veins. This dilatation is also attended by an increase in the 
length of the vessels, and they become more or less tortuous. 

The enlargement of the vessels is attended at the outset of 
the process with an acceleration in the flow of blood, but this 
is soon followed by a retardation of the flow, the vessels re- 
maining dilated. As the circulation becomes slower, the white 
corpuscles, or leucocj^tes, accumulate in the veins, and their 
natural tendency to adhere to the sides of the vessels is in- 
creased to such an extent that they nearly fill the calibre of the 
tube, and accumulate against its walls, remaining almost sta- 
tionary while the blood-current passes by them, though with a 
greatly diminished velocit3^ Those immediately in contact 
with the wall of the vessel are now seen to press against it, and 
finally to pass through into the tissues beyond, simply tran- 
suding the wall, the opening closing up behind them. 

2. Associated with the passage of the blood -corpuscles is 
the exudation of liquor sanguinis. This exudation, which con- 
stitutes the well-known inflammatory effusion, difi'ers from the 
effusion which escapes from the blood-vessels in simple mechan- 
ical obstruction, as in dropsy from heart disease, or cirrhosis, 



INFLAMMATIOISI OF MUCOUS MEMBRANES. 39 

in containing an amount of fibrin and albumen, varying with 
the extent and severity of the inflammatory process. 

3. The remaining constituent of inflammation is the altera- 
tion in the nutrition of the inflamed tissue. Tlie cells which 
constitute a normal part of the tissue take on an increased ac- 
tivity ; the normal processes of physiological growth become 
greatly exaggerated, and new cells are developed by one of the 
methods before alluded to. 

This in brief completes the picture of inflammation in gene- 
ral. Confining ourselves now to mucous membranes, we find 
certain peculiarities manifesting themselves in the processes. 

Inflammation of mucous membranes occurs in three different 
varieties : catarrhal, croiqyous, and diplitlieritic. 

Oatarrlial inflammation. — This is by far the form most 
frequently met with. In its milder degrees it is characterized 
merely by an increased secretion of mucus. An increased flow 
of blood to the parts, occurring at the outset of the process, 
seems to stimulate the cell-elements to an abnormal activity, in 
which new cells are generated ; the glands pour out their nor- 
mal secretion in excessive quantities ; an abundant liquor san- 
guinis transudes the vessels ; and the result is an increased 
secretion of mucus, which is highly charged with young cells, 
many of them having their source within the epithelial cells, 
while others are emigrant blood-corpuscles. The membrane at 
the same time becomes swollen and reddened as the result of 
the increased vascularit}^ 

If the irritation be more severe the vascular phenomena are 
more marked ; the cell-generation is more rapid ; and as the re- 
sult of this rapid generation they seem to fail of attaining ma- 
turity, and are poured out in an unripe state ; hence they are 
smaller, and not so well developed. Many of these imperfectly 
developed cells cannot be distinguished from pus-corpuscles ; 
while others are larger and resemble the mucus-corpuscle or 
leucocyte. Between the macus-corpuscle and the pus-corpuscle 
we have no method of distinguishing, except that the former 
is larger and of a somewhat more regular outline. The epithe- 
lium also loosens and falls off more rapidly from the surface of 
the membrane, under the stimulus of the inflammatory process ; 
and as it progresses we have the mucous discharge gradually be- 
coming a purulent one, from being so higlil}- charged with these 
unripe cell-elements, many of which are virtually pus-cells. 



40 MUCOUS MEMBRANES. 

The process continuing, its activity, which so far has been 
largely confined to the superficial layer of the membrane, ex- 
tends to the sub-epithelial layer, or the mucous membrane 
proper, which now becomes more involved, and the cell-ele- 
ments here take on renewed activity, and becoming rapidly 
generated, they distend and infiltrate the parts. The membrane 
becomes thickened and more swollen ; and there now may occur 
several secondary manifestations of the infiammatory process. 
As the result of the loss of surface epithelium, the membrane 
may become denuded of its epithelial coat, and there may oc- 
cur an abrasion or so-called catarrhal ulcer. As the result of 
the distention and infiltration of the membrane proper, the 
glands may become so choked that their contents are impris- 
oned, and as the result, there is formed a minute abscess, which 
breaking and discharging, there is left a small ulcer. The acute 
process may subside or it may lapse into the chronic state. In 
this the increased vascularity subsides to an extent, though 
the vessels remain permanently somewhat dilated. The cell- 
production, however, goes on both in the epithelial layer and in 
the mucous membrane proper ; and the increased secretion per- 
sists ; but all in a somewhat diminished degree. 

Chronic catarrh differs from acute catarrh in that in the for- 
mer the sub-epithelial layer of the membrane is much more in- 
volved. It is thickened and indurated by its infiltration with 
the young cells before spoken of, the mucus-corpuscles, and 
migrating blood-corpuscles ; and also by a renewed activity in 
another elemental tissue of the membrane, viz., the connective 
tissue, which plays an important part in chronic infiammation. 
This tissue is developed now b}^ a slow process of pi'olifeia- 
tion, and b}^ its peculiar characteristics gives rise to those fea- 
tures of chronic catarrh which render it extremely obstinate to 
manage. 

Having been once developed it is probable that connective 
tissue is never absorbed, or excreted as the other cell-elements 
in catarrh ; but becoming organized, it remains a permanent 
element in the membrane to deform, disorganize, and interfei'e 
with its proper function. As the result then of the new deposit 
in the membrane, we may have its normal thickness so much 
increased as not only to interfere with its proper function, but 
also to impair by mechanical means other functions ; as in the 
hypertrophied membrane of the nose, causing nasal stenosis, 



INFLAMMATION" OF MUCOUS MEMBRANES. 41 

and thereby interfering witli normal nasal breathing. Again, 
this tissue may be so deposited as to press npon the glands and 
follicles of tlie membrane in such a manner as to cause their 
atrophy, thus robbing the membrane of its proper supply of 
lubricating fluid, its mucus, and giving rise to the so-called 
dry catarrh. It may be deposited about the individual folli- 
cles or glands in such a manner as to press upon the outlet 
alone, thus closing them up, giving rise to small cysts ; or 
their contents becoming imprisoned, undergoing fatty degen- 
eration, and acting as a renewed source of irritation, there may 
occur a glandular hj^pertrophy of an individual follicle or 
gland, giving rise to the so-called follicular inflammation. 

Croupous inflammation.— T\\is form of inflammation is of a 
higher grade and of a more intense form than the catarrhal ; 
for while it commences in the same manner, with distention of 
the blood-vessels, escape of liquor sanguinis and blood-corpus- 
cles, and proliferation of cells, it differs from it in the fact that 
the exuded liquor sanguinis contains a large amount of fibrine 
and albumen, which coagulates upon the surface of the mem- 
brane, and forms a false membrane. This false membrane is of 
a more or less dense. Arm character, and is composed of fibrine 
enclosing a large number of epithelial cells in its meshes. At 
times it may be soft and almost granular in character, so much 
so that it may be easily removed with a soft brush, coming 
away in small broken particles. At other times it may be of 
so dense a character, that after removal it can be torn only with 
considerable force. As a rule it can be easily removed, leaving 
the membrane beneath it in the main intact, merely deprived 
of some of its superficial epithelial cells. After removal, the 
same process may be renewed and a new membrane form, or 
the parts may be restored to their normal condition. 

The favorite site for this form of inflammation is in the 
upper air-passages, the pharynx, tonsils, larynx, and trachea, 
though it may occur in the bronchi, intestinal canal, and other 
parts. 

Why this form of inflammation occurs it is impossible to 
state ; but it is not improbable that it is due to some previ- 
ously existing blood condition, which dominates the inflamma- 
tory process, and so enriches the exuded liquor sanguinis with 
the fibrinous material, that it coagulates on its exposure to the 
ail-, and so a false membrane is formed in place of the fluid 



42 MUCOUS MEMBRANES. 

catarrhal discharge. Further evidence that this form of in- 
flammation is due to some previous condition in the blood, is 
afforded by the fact that its onset and course are usually marked 
by a febrile movement far more aggravated in character than 
we would expect to find as merely symptomatic of so limited 
an extent of local inflammation. The temperature in simple 
membranous sore throat, characterized by a croupous deposit 
on the tonsil, often ranges as high as 103° — 104°. 

Croupous inflammation may manifest itself in a fibrinous 
exudation on the surface of a mucous membrane, as in croupous 
larj^igitis, or true croup, membranous sore throat, croupous 
pharyngitis, etc. ; or the exudation may take place into the 
follicles of the membrane, giving rise to an acute follicular in- 
flammation, such as occurs in the affection generally known as 
acute follicular tonsillitis, which is a croupous inflammation 
of the tonsil, in which the exudation takes place in the crypts 
of the organ rather than upon its surface. 

Diphtheritic injlammatloii. — This variety of inflammation 
again is characterized by the formation of a false menibrane, 
and also commences as a catarrhal inflammation, with its in- 
creased blood flow, cell-pi'oliferation, and exudation of liquor 
sanguinis, the exudation, as in the croupous form, containing 
largely of flbrineand albumen ; but there is this difference, that 
while in the croupous form the exudation is poured out upon 
the surface of the mucous membrane, in the diphtheritic form it 
permeates and inflltrates its whole thickness down to the sub- 
mucous tissues. 

This exudation permeates the membrane so densely that in 
coagulating it completely destroys its vitality, and there is 
formed a dead membrane, involving the whole thickness of the 
mucous membrane. It is removed with considerable difficulty ; 
and in its removal, carrying with it the whole thickness of the 
membrane, leaves the parts beneath entirely denuded, a raw 
surface. The false membrane declares itself to the eye as a 
dead membrane ; a genuinely necrosed or sloughing tissue, of 
a dark grayish color, resembling boiled maccai'oni; in contra- 
distinction from a croupous membrane which is of a bluish, 
pearl-gray color, presenting no appearance of necrosis, but 
rather of an unmistakably living tissue. 

It should be understood in regard to these terms, croupous 
and diphtheritic inflammation, that they only refer to forms 



INFLAMMATIOlSr OF MUCOUS MEMBRANES. 48 

of inflammation to which mncous membranes are subject, and 
not to the specific diseases which are spoken of under the 
names croup and diphtheria ; as for instance, membranous 
croup is generally understood to be a croupous inflammation 
of the mucous lining of the larynx, although a better classi- 
fication would suggest the more expressive and correct name of 
croupous laryngitis ; and also of diphtheria, it is a blood dis- 
ease, characterized by a local manifestation in the throat, con- 
sisting of an acute inflammation of its mucous membrane, which 
assumes the diphtheritic form ; so that when we speak of croup- 
ous and diphtheritic inflammation, we simpl}^ deflne the form 
which the inflammatory process assumes. 

In regard to catarrhal inflammation or, as it is generally 
called, catarrh, the same may be said ; properly speaking, it 
means that form of inflammation of a mucous membrane which 
is characterized by an excessive discharge of mucus or muco- 
pus ; but a better usage in the direction of an exact classiflca- 
tion would suggest that the local designation should be pre- 
fixed, as nasal, laryngeal, bronchial catarrh, etc. 



CHAPTEK III. 

METHODS OF TREATING MUCOUS IVIEMBRANES, AND THE USE 
OF INSTRUMENTS. 

In order to avoid unnecessary repetition when we come to 
the consideration of special diseases, it would seem best to de- 
vote a chapter here to the consideration of the various methods 
by which topical remedies are applied. It is safe to say that 
the success in the management of those affections which require 
local medication is due, not so much to the remedies used, as 
to the thoroughness and efficiency with which the parts are 
reached. Tliis thoroughness and efficiency is only attained in 
many cases by the use of ingeniously devised instruments, 
combined with a certain nicety and deftness of manipulation. 
The idea' is by no means intended to be conveyed that these 
diseases should be treated at the hands of experts alone, for I 
have always entertained the conviction, and urged it in my 
teaching, that the laryngoscope should be in the hands of every 
physician, not as a piece of ornamental office furniture, but as 
an efficient and indispensable aid in the diagnosis and treat- 
ment of diseases of the air-passages, and that the special skill 
necessary to use it intelligently, and to manipulate the instru- 
ments requisite for the efficient treatment of diseases recog- 
nized by its aid, is acquired with the utmost facility and ease 
by any physician who will devote to it the time needed to master 
its simple philosophy ; and who also possesses that general 
deftness in the manipulation of all instruments which becomes 
natural and easy to every practitioner. 

The usual applications that are made to mucous membrane 
may be classified as solids, powders, and liquids. 

Solids.— The use of solids for topical application is some- 
what limited ; nitrate of silver, either pure or in the mitigated 
form, being used more than all others. This may be used with 
the ordinary porte-caustique of the pocket case in the anterior 



THE USE OF INSTRUMENTS. 45 

nares or mouth, but when there is the least danger of its becom- 
ing detached and falling into the air-passages, the simple device 
should always be resorted to of fusing it on the end of a wire 
which may be bent at any angle to fit it for the special applica- 
tion it is desired to make. Mackenzie recommends for this 
purpose an aluminum wire, slightly roughened at its extremity, 
which is to be dipped into the silver, fused over a spirit-lamp. 
An ordinary copper or steel wire answers the purpose quite 
well. It may be held in the flame for a moment, and then 
touched to the stick of caustic, and by its own heat it will melt 
a small amount, which, adhering to it, is quite sufficient for a 
single application. 

Other agents, such as alum, sulphate of copper, borax, 
chromic acid, etc., may be used in the solid form, but, as a 
rule, where they are used for their astringent properties, they 
are more efficacious in the form of powders, or in solution. 

Powders.— The use of powders, or snuffs, as topical reme- 
dies, provided they are properly and thoroughly applied, is of 
very great value in the treatment of diseases of the upper air- 
passages, but, undoubtedly, in many cases they fail of their 
proper effect by not thoroughly reaching the parts which it is 
desired to medicate, while in others they do harm by not being 
properly used. This is in the main due to the instruments by 
which they are ajDplied. 

Various powder blowers or insufilators have been devised, 
some of them excellent instruments, while others are, undoubt- 
edly, at times, not only inefficient, but even mischievous. 

Fig. 44 represents the Rauchfuss insufflator, a fenestrated 




Fio. 44. — RauchfuKS powder insiilTlutor. 

tube bent at its extremity to adapt it for carrjdng the powder 
in the desired direction. At the otiier end is fitted a rubber 
air-ball. A movable slide fits over the feiicsirum. Tlie ])ow- 
der having been placed in the tube through the feiiustrum and 
the opening closed by the slide, a quick pressure on tlie air- 
bulb drives a current of air tlirougli the tube, which cariying 
the powder before it, deposits it in a mass upon the part lo be 



46 



METHODS OF TREATING MUCOUS MEMBRANES, 



medicated. The one advantage of the instrument is that it en- 
ables the operator to estimate the exact amount of powder used. 

The disadvantage of this class of 
instruments is that the powder 
is deposited in mass, piled on the 
part, as it were, and where these 
are especially sensitive, may 
cause irritation, and thereby do 
harm. The}^ also fail to thor- 
oughly diffuse it. where it is desired to medicate a large sur- 
face, or reach throughout a sinuous cavity. 

Fig. 45 represents a modification of Rauchfuss' instrument. 




Fig. 45. — Leflferts" modification of Rauchfuss' 
insufflator. 




Fig. 46. — Powder insufflator with mouth-pii 



by Dr. Lefferts, in that the air-bulb is placed on the upper side 
of the tube in su(,'h a position that it is pressed by the fore- 
finger, in place of the thumb, as in the original instrument. 




Fig. 47.— Smith's powder insufflator, with movable tips for making applications to the anterior or 
posterior nares. and larynx. 

This is an improvement only in that it renders the manipula- 
tion somewhat less awkw^ard. 

Fig. 46 represents another device, in which there is substi- 



ATSTD THE USE OF INSTRUMEISTTS, 



47 



tuted for the air-bulb a piece of rubber tubing, terminating in 
a moutli-iDiece. As will be seen, the powder is simply blown 
upon the parts. This is a far more efficient 
instrument than either of the others, in that 
the powder is more thoroughly diifused by the 
stronger current of air by which it is propelled. 

Fig. 47 represents an insufflator, first suggest- 
ed, I believe, by Dr. A. H. Smith, of New York, 
which consists of a wide-mouthed bottle, through 
the cork of which thei-e pass two tubes bent at 
right angles above ; to one of the tubes is attached 
an air-bulb, while the other is bent at its distal 
extremity, upward or downward, or in whatever 
direction it is desired to carry the powder. The 
tube to which the air-bulb is attached passes 
down into the lower portion of the bottle, while 
the other merely passes through the cork. The 
powder having been placed in the bottle, a quick 
pressure on the air-bulb drives a current of air 
down into the bottle, which striking the powder 
stirs it up into a cloud, and at the same time 
drives it out through the other tube, and deposits 
it upon the part it is desired to medicate, in a 
state of line and even diffusion. This instrument 
can be obtained of the instrument makers, made of 
hard rubber, or any one having a stock of glass l||| 
tubing may make his own supply. This is un- 
questionably the best insufflator in use. Its ad- 
vantages are that it thoroughly diffuses tlie pow- 
der ; that it deposits it in a smooth, thin film ; 
that it does not pile it on any of the parts, and g \ 
that it carries it throughout the sinuous cavities. 
Its only disadvantage is, that it does not enable 
the operator to estimate nicely the amount of 
powder used, though as a rule this is of no conse- 
quence. Fig. 48 illustrates Stoerck's insufflator 
which combines the advantages of all the above- ^ .o o 

" Fig. -18.— Stoerck's 

mentioned instruments. It consists of a small powder insufflator. 
central chamber for the reception of the powder, fitted with a 
movable cover. Projecting from this is the long curved tube 
for directing the medicament to the part it is desired to reach. 



48 METHODS OF TREATING MUCOUS MEMBRANES, 

Afc its proximal end it is fitted witli a tapering socket com- 
municating witli the powder chamber by a tube containing a 
spring cut-off. This instrument is intended for use in connec- 
tion witli the compressed air apparatus. Its working is obvi- 
ous; the distal point being placed in position to throw the 
powder in the desired direction and the instrument connected 
with the air-chamber, pressure on the valve lets on a sudden 
blast, which drives the powder to the spot intended to be 
reached . 

The advantage to be gained by the use of powders is a cer- 
tain amount of permanency of action, as they remain for some 
time in contact with the part, and becoming slowly dissolved 
in the mucus, are absorbed by the membrane. The remedies 
usually employed in this form are, tannin, bismuth, alum, 




Fia. 4!).— Tuerck's brush. 



borax, ferric alum, zinc, nitrate of silver, iodoform, opium, 
morphia, belladonna, benzoin, sanguinaria, galanga, etc. 

When it is necessary to reduce the strength of an agent, it 
may be combined with pulv. cretfe, pulv. acacise, magnesise car- 
bonat., saccli. alb., etc. If the jjowder is heavj^ it may be ren- 
dered lighter by combining with powdered starch or lyco- 
podium. 

Liquids. — In the form of alcoholic tinctures or watery solu- 
tions, liquids form a large proportion of the remedies ordinarily 
iised for topical medication. 

They are applied by means of the brush, sponge, cotton 
pledget, syringe, douche, and in the form of spray, by one of 
the numerous devices for atomization. 

The hrusli. — For convenience and cleanliness it is well to 
have some such an affair as Tuerck's brash, shown in Fig. 49, 
which consists of a w^ire mounted in a handle and with a thread 
turned on its distal end. It is supplied, by the instrument 
makers with a dozen or more cameFs-hair brushes, mounted in 



AND THE USE OF HSrSTRUMENTS. 49 

brass sockets, of varioas sizes, which may be screwed on the 
handle as needed. It can easily be adapted for the different 
applications in the larynx, pharynx, etc., by simply bending 
the wire. 

Fig. 50 represents Mackenzie's brush, which consists of a 
horn-monnted eamel's-hair brush on the end of a wire which is 
bent at an angle nearly approaching a right angle. Of course 
for applications to the pharynx or anterior nares the ordinary 
quill brush, mounted on a slender holder, is all that is neces- 
sary. 

The use of the brush is much resorted to, especially among 
the English and Germans, and largely in the treatment of laryn- 



PiG. 50. — Mackenzie's brush. 



geal diseases, as well as diseases of the pharynx. It has always 
seemed to me that, when it is desired to nicely localize an ap- 
plication, the brush fails to accomplish it, and, on the other 
hand, when it is desired to treat broad surfaces, especially in 
the larynx, that we have other and far better methods. There 
is also^the annoyance of hairs becoming loosened from the brush 
and falling into the air-passages. 

Cotton pledget. — A very simple method of applying liquids 
is by means of an ordinary probe wrapped with a small pled- 
get of cotton. It is cleanly, it avoids dripping, and it localizes 
very nicely when it is desired to touch only a small diseased 
surface. All tliat is necessary is a piece of ordinary wire, which 
should be roughened at its end to prevent tlie cotton from slip- 
ping off and dropping into tlie air-passages. To adopt it for 
the different applications the wire can be easily bent in any 
direction. A very ingenious device for using the cotton pledget, 
consists of a wire, on the end of which is turned a coarse thread, 
\\iii(;h renders the escape of the cotton impossible ; and also, 
4 



50 



METHODS OF TREATITiCx MUCOUS MEMBRANES, 



wliicli is of no little convenience, renders the removal of the 
(^otton, after using, extremely simple ; the wire point is merely 
unscrewed from the cotton. 

Sponges. — The main objection to the use of the sponge is 
that there is a danger of its becoming detached from the sponge- 
holder and falling into the air-passages. This danger being 
obviated by the use of a safe and reliable instrument, the sponge 



Fig. 51. — Ordinary sponge-hokler. 

is unquestionably preferable to either the brush or cotton ; 
in that it holds the medicated fluid well in its meshes, and 
avoids dripping ; it is cleanly, a new piece being used for each 
application ; it is convenient, and can be easily fashioned, in 
size and shape, to adapt it to each case in which it is used. 

Fig. 51 represents the simplest form of holder, a split wire 
with toothed jaws which are held together by a sliding ring. 




Fig. 52. — Elsberg's spring forceps sponge-holder, with Mackenzie's modification, consisting of : a 
safety wedge (x) : A,' the forcejis open ; B, the forceps holding the sponge. The safety wedg.,' (x) is raised 
in A, but closed in B. (Mackenzie.) 



The teeth are very liable to become eroded by the agents used, 
and thereb}^ their grasp of the sponge becomes insecure. 

Fig. 52 represents Elsberg's spring-forceps sponge-holder. 
The same objection lies against this instrument as against the 
former, that the teeth easily become rusted or eroded. There is 
the additional objection that the grasp of the sponge is only by 
the strength of the spring, which is at least unsafe. Macken- 



AND THE USE OF INSTRUMENTS, 



51 



zie has added to this, a wedge shown at x in Fig. 52, which ren- 
ders it more secure. 

Fig. 53 represents Elsberg's improved sponge-holder, unques- 
tionably the best and safest instrument yet devised. The figure 
easily explains itself. The intrument consists of two blades 




Fig. 53. — Elsberg's improved sponge-holder. 



joined together by the ordinary obstetric forceps lock. While 
t]ie instrument is in use the handles are held together by the 
slide and the sponge is grasped with perfect security; as soon 
as the slide is withdrawn the blades fall apart and the sponge 




Fig. 54. — Postnasal syringe. 

falls out. The facility with which the instrument can be cheaned 
is an additional recommendation. 

Syringes. — Fluids may be thrown against the diseased mem- 
brane of the larynx, pharynx, or nasal cavity by means of 
syringes, of forms variously devised for special ends. Fig. 54 
shows tlie ordinary post-nasal syringe, a common barrel syringe. 




fitted with a curved tube wliicli l«'i iiiinates in a rose douche, 
delivering jets in every direction. This ma}^ be passed up behind 
the soft palate for injecting through the nasal cavities, or it 
may be turned dowuAvard for injecting the pharyngeal cavity. 
Fig. 55 represents the \)\\n', of the same syringe fitted for using 



52 METHODS OF tkp:ating mucous membranes, 

with the Davidson syringe. It is equally adapted to the foun- 
tain syringe. For injecting through the anterior nares an or- 
dinar}^ ear syringe answers the purpose verj'" well, but better 
still is the post-nasal syringe shown above (Fig. 54), with the 
tube straightened. This can be introduced well into the cavity 
if desired. 

Fig. 5(j represents an ingenious little sja-inge for injecting 
a small quantity of liuid into the laryngeal cavity, which con- 
sists of a hard rubber tube of small calibre bent at the proper 
curve for reaching into the larynx. A small chamber on its 
upper side which is 'covered b}^ a rubber diaphragm communi- 
cates with the hollow of the tube. Its action is sufficiently 
obvious. The point of the syringe being immersed in the fluid 
to be used, the flnger is pressed on the diaphragm and the air 
is thus expelled from the chamber. As soon as the pressure 




Fig. 56. — Hartcwelf s laryngeal syringe. 

is removed the fluid passes into the chamber, from which it is 
again easily discharged at will upon the part to be medicated 
in as small a quantity as may be desired. Syringing is rarely 
resorted to in the laryngeal cavity, but in the nasal cavity is al- 
most indispensable. The force with wliicli the stream is driven, 
and the direction in which it is thrown, being entirely under 
the control of the operator, the thorough cleansing of the pa^M;s 
is accomplished with comparative ease ; for it is in this j^repar- 
atory cleansing that the s^ainge is of the most value in the 
treatment of catarrhal affections. 

The nasal douche. — The principle on which the nasal douche 
is constructed is, that if a fluid passing from a vessel held at a 
distance above the head, and flowing through a tube, is allowed 
to enter one nostril, the head being inclined forward, it will fill 
the nasal cavity of that side on which it enters and, overflow- 
ing the septum, pass out through the other nostril, the soft 
palate elevating itself and preventing the fluid from escaping 
into the pharynx. 



AISTD THE USE OF INSTRUMENTS. 



53 



Fig. 57 represents the ordinary form of the Weber douche. 
The reservoir may be a simple cup of tin, or a glass bottle. 

Fig. 58 represents a simple device for accomplishing the 
same purpose, suggested by Thudichum. It is composed of 
a rubber tube, with a heavy 
metal perforated disk at one 
end, and a nose-piece at the other 
end. By filling the tube by suc- 
tion or immersing it in the fluid, 
and dropping the weighted end 
in a jar of fluid held above the 
head, a syphon action is estab- 
lished, and an excellent douche 
is obtained with a much sim- 
pler and more portable appa- 
ratus. To avoid the difficulty 
and awkwardness which many 
patients encounter in their at- 
tempts at filling the syphon 
douche and getting it to work 
IDroperly, Cohen has added a 
compression bulb to the tube, as 
shown in Fig. 59. The syphon 
being in position, a single pres- 
sure on the bulb, while the tube at the nasal end is closed by 
pinching in the fingers, will be sufiicient to fill it with the fluid 
and set it in action. Fig. 60 illustrates the method of using 




Fig. 57.— Webei 
of using it. 




Thndichum's syi)hoii douche. 




Fig. .50. — Cohen's modification oC Tluidichuni's syphon. 



the sy])hon. The true value of the nasaWouclx' is in tlie facil- 
ity with which it can be used by patients sufi'ering from nasal 
disorders, in the intervals of treatment at tlie hand of the phy- 



54 



METHODS OF TKEATIXG MUCOUS MEMBRANES, 




Fig. 60. — Method of arranging the sj'phon 
douche. tCohen.) 



sician. It aids the x^hysician in liis efforts to cure these obsti- 
nate affections, and palliates and relieves the s3^mptoms of the 
patient ; but that it ever accomplishes a radical cure is ques- 
tionable. The flow of the medicated fluid through the nasal 
cavity is very slow and sluggish, and certainly in the more 
aggravated cases fails to cleanse the parts of the masses of dried 
mucus and pus which lodge in and adhere to the sinuous cavi- 
ties of the nose. It is very doubtful, also, whether the fluid 

more than reaches to the mid- 
dle meatus, it being more prob- 
able that most, if not all of it, 
passes through the inferior 
meatus. 

It has been charged by 
Knapp, Roosa, and others, 
that the use of the nasal 
douche has caused inflamma- 
tion of the Eustachian tube 
and middle ear, with conse- 
quent loss of hearing. When 
we consider the very large 
number of j^ersons with impaired hearing as the result of ca- 
tarrh of the naso-phaiy-ngeal cavity, extending to the auditory 
apparatus through the Eustachian tube, and who have never 
used the nasal douche, it becomes a nice question to decide 
as to how far the douche is responsible for deafness occurring 
in those who may have used it. Certainly there is fair ground 
for regarding it an open question wiiether the use of the douche 
or the original catarrh is responsible for the impairment of 
hearing. Still the instrument should never be used without 
keeping in mind this possible danger. 

The fluids used should always be rendered of a decidedl}'" 
alkaline reaction, by the addition of common salt, soda, lime- 
water, or some other simple agent, and should be of a temper- 
ature not below 70° or 80°. 

Atomizers or spray producers.— The idea of making use of 
fluids in a state of flue subdivision for application to the air 
passages, dates back as far as 1849, when the proprietor of one 
of the medicinal springs of France, thinking that if the waters 
of the spring possessed anj^ virtues when taken into the alimen- 
tary canal, their benefits might be greatly enhanced when 



AND THE USE OF INSTRUMENTS. 



55 



taken into the air-passages, conceived the plan of projecting a 
large number of small jets of the water against the wall of a 
room especially prepared for the purpose, thus breaking it up 
into a state of Une atomization and filling the room completely 
with the spray. Into this room, patients well protected by 
rubber oversuits were introduced for the purpose of inhaling 
its surcharged atmosphere. The idea was received with great 
favor by medical men, and immediately adopted as a most 
valuable addition to our methods of treatment ; but the plan 
by which the atomization was accomplished has been improved 
upon and simplified to such a degree, that w^e now possess a 
large variety of ingenious little instruments which render topi- 
cal treatment by atomized fiuids not only very simple but quite 
efficacious. 

There are two principles on which these instruments are 
constructed. One of these is best illustrated by the atomizer. 




Richardson's atomizer with double bulbs. 



generally known in this country as Richardson's, shown in 
Fig. 61. The projecting portion consists of two hard rubber 
tubes, one within the other. To the outer tube is fitted, at its 
distal extremity, a movable cap, perforated in its centre by a 
small opening. The inner tube passes from immediately behind 
the opening in the cap, through the centre of the outer tube, 
through the neck of the reservoir, and down into the fiuid. 
The small j^rojecting nipple on the neck of the bottle or reser- 
voir, is for the attachment of the air-bulbs which furnish the 
air-pressure. It opens into the larger tube, and also communi- 
cates with the reservoir. As will be seen, when a current of 
air is pumped in by the bulbs, it is divided into two streams. 
One stream passes into the reservoir above the fluid, where, 
being compressed, the fluid is forced up through the central 
tube and driven in a small jet against the opening in the mov- 



56 



METHODS OF TREATING MUCOUS MEMBRANES, 



able cap. The other current from the air bulb passes into the 
larger tube and escapes through the opening in its movable cap. 
The small jet of the liuid striking against the edge of the small 
opening in the cap, and at the same time meeting with the 
current of air escaping therefrom, is broken up into a fine 
spray, and in this state is carried with the current some dis- 
tance beyond the tube. In order to deflect the current of spra}^ 
upward or downward, a separate movable cap is supplied, fitted 
with a curved projection, as shown in the figure. 

A single air bulb of course would give an intermittent cur- 
rent ; hence to overcome this there is added a second and more 




Fig. 02. — Sass's spray tube's with the automatic cut-ofE. 



elastic bulb, between the hand- bulb and the atomizer, which 
receiving the air^from the hand-bulb and becoming distended, 
exerts a continuous pressure by its elasticity, and furnishes a 
steady and constant stream of the spray. A larger set of bulbs, 
constructed on the same principle, but designed to furnish a 
more powerful current of air, is shown in Fig. 64, the foot being 
nsed in place Qt the hand. The other principle on which atom- 
izers are constructed is that of Bergson. This is best illus- 
trated by what is generally known as Sass's spray tubes, which 
consist of two heav}^ glass tubes joined together, as shown in 
Fig. 62. To one of the tubes is attached the tubing which is 
connected with the air-pressure, while the other leads down into 



AND THE USE OF IISrSTRUMENTS. 



57 



the reservoir containing tlie fluid designed to be atomized. The 
extremities of the tubes are so fashioned that the current of 
air from the air-chamber strikes against the orifice of the tube 
leading to tlie fluid, at a 
right angle, thus creating 
a tendency to a vacuum at 
that point by which the 
fluid is drawn up in the 
tube, and overflowing its 
extremity, is broken into 
a fine spray by the jet of 
air which strikes it as it 
escapes. The tips of these 
tubes may be fashioned to 
throw a current upward, 
downward, or forward, as 
shown in the figure. This 
is the principle on which 
the ordinary cologne atom- 
izers are constructed, which are sold in the drug stores. 
There is also shown in Fig. 62 a convenient little stop-cock or 
cut-off attached to the spray tube, by which the current of 



^^te 



-Single hand-ball atomizer. 




Fia. 64. — Newman's spray tubes, with 



compressed air may be let on or sliut off at will. Of atomizers 
constructed on this plan quite a useful little afl:'air is that 
shown in Fig. 63. It is a very simple and inexpensive instru- 



53 



METHODS OF TREATING MUCOUS MEMBRANES, 



iiient, and convenient for ordinary applications to the nose or 
throat where an instrument is desired for family use. 

Dr. Newman, of New^ York, has devised an ingenious modi- 
fication of the Bergson tubes, in which one tube, as shown in 
Fig. 64, is contained within the other, the principle on which 
it operates being the same as that of the Sass tubes. This is an 
excellent atomizer, producing a fine spray ; the main objection is 
that it is extremely fragile. For the Richardson atomizer or 
Newman's tubes, suflicient pressure is obtained by the use of 
the double air-bulbs, but it is often desired that a stronger pres- 
sure should be available. For this purpose an air-pump and 
receiver may be used, as shown in Fig. 65, attached to the Sass 




tubes. The advantage of the air condenser, by wliich a pres- 
sure reaching as high as fifty pounds can be obtained, cannot 
be overestimated, for where it is desired to make applications 
to the sinuous cavities of the nose, or to the larynx, the feeble 
pressure obtained by the use of the air-bulbs is insufficient. 
Another objection to the use of the air-bulbs is that the current 
of spray is not absolutely and immediately under the control of 
the operator ; that is, it cannot be let on or shut off at the instant 
often desired. As will be seen by the figure, this object is easily 
obtained by the use of the air-receiver. The atomizing tube be- 
ing attached, and the receiver being charged with air, the current 
is held under control by the thumb pressed firmly against the 



MAKING APPLICATIONS. 59 

proximal end of tlie tube, or by the automatic cut-off shown in 
Fig. 62, and the pressure can be let on or shut off instantane- 
ously, and at will. A serious objection to the use of the pump 
and receiver heretofore has been the high price at which they 
are sold ; they can now, however, be obtained at a cost that 
ought to be within the reach of every practitioner who is called 
on to treat even a moderate number of catarrhal cases, as by 
their use a greater thoroughness and efficiency is obtained in 
making topical applications to the upper air-passages than by 
any other method. 

MAKING APPLICATIONS. 

In making applications to the pharynx and anterior nares 
the method is sufficiently obvious and requires no special direc- 
tions. But the method of making applications to the larynx 
and posterior nares requires some further remark. 

Applications to tlie larynx. — Passing a probe, brush, or 
sponge into the larynx for the purpose of medication demands 
a special skill only obtained by practice. Before the introduc- 
tion of the laryngoscope it was claimed by Horace Green and 
others that the probang could be passed directly into the larynx 
and trachea. Whether this was really done by Dr. Green, has 
been called in question ; certainly in our day no one would 
dare attempt this manipulation without the use of the laryn- 
geal mirror. In making this application, the mirror being placed 
in position, held in the left hand, the brush or sponge is passed 
directly back to the fauces until its image is seen reflected in 
the mirror. It is then turned and passed directly down into 
the larynx, the important point being always held in remem- 
brance, that for the proper accomplishment of this procedure, 
the brush or sponge should never be lost sight of until it has 
reached tlie part it is desired to medicate. This to a beginner 
will oftentimes prove an extremely awkward and difficult man- 
ipulation, and as a rule should not be attempted on the living 
subject, for the first time, but should only be resorted to after 
some practice on the model or some other of the many simple 
devices which have been suggested. I have generally directed 
my students to practise the following plan : a small, wide- 
mouthed bottle being placed behind a book is made to rej^re- 
sent the larynx, the laryngeal mirror being held above it and 



60 METHODS OF TREATING MUCOUS MEMBRANES. 

the light thrown upon it from the liead-mirror, tlie stndent is 
directed to pass the laryngeal probe, by the aid of the mirror, 
into the bottle and down npon a bit of paper or other object 
l3dng upon the bottom. Hy a little simple practice of this 
kind the beginner will easily acquire sufficient skill to make 
application to the living larynx. The special skill required is 
that of guiding'the point of his laryngeal probe or brush by 
the reflected image rather than by the direct view. The ap- 
plication of sprays to the larynx has been objected to on the 
ground that they are unphysiological and impracticable ; these 
objections are certainly not tenable. The larynx in health is 
extremely sensitive and intolerant of the introduction of any 
foreign substance. This characteristic is still more marked in 
disease. In making applications to the larynx, then, it is de- 
sirable that this sensitiveness should as far as possible be re- 
spected. The use of the probe, the brush, or the sponge in 
making topical applications, necessarily involves the carrjang 
into the organ, as a vehicle for the agent employed, a more or 
less rude, hard, or harsh foreign body. In the use of the sprays 
for laryngeal applications, the vehicle by which the topical agent 
is carried to the part in no way touches or impinges upon the 
diseased surface, but on the contrary, the fluid is deposited in 
a state of fine atomization, is showered on the part as it were, 
thus reaching it in a way which certainly on theoretical grounds 
ought to prove the least irritating, the most thorough, and the 
most efficacious of all our methods of treating the larynx. The 
charge that spraying the larynx is unphj^siological, can only 
be met by the assertion that the same law holds good in regard 
to most measures to which physicians are compelled to resort 
in the management of disease ; and furthermore that if the 
use of the spray is open to this objection, the use of the brush, 
the sponge, and the probe are far more so. The charge that 
the application of atomized fluids to the larynx is impractica- 
ble needs no comment. That the spra}^ can be thrown directly 
into the laryngeal cavity, if the atomizing tubes are properly 
manipulated, cannot be questioned. In accomplishing this 
procedure the tongue should be protruded and held between 
the thumb and forefinger of the left hand, while the laryngeal 
spra}^ tube, held in the right hand, is passed into the mouth 
until its beak is beyond the crest of the epiglottis. The patient 
should now be directed to sound "ah," when the pressure be- 



MAKING APPLICATIONS. 61 

ing let on, the whole cavity will be flooded with the spra}^ 
The act of phonation, of course, closes the rima-glottidis, and 
thus the fluid does not make its way beyond the vocal cords. 

I have long entertained the conviction, that in the spraj^ we 
have a method of reaching these parts more thorough and less 
irritating than any other, and for this consideration long ago 
abandoned almost entirely the use of the brush and sponge ex- 
cept in those cases where it was desired to nicely localize the 
action of a remedy. 

Applications to tlie upyer pliarynx. — The main obstacle to 
reaching the upper pharynx with topical agents is the ten- 
dency on the part of the palatal muscles to contract on the 
slightest provocation, thus closing up the opening through 
which the applications are made. To surmount this hindrance 
the main reliance will be on educating the patient to a proper 
control of the faucial muscles, by which the palate may remain 
completely relaxed and the naso-pharyngeal orifice patulous. 
To secure this access to the upjDer pharynx, various palate re- 
tractors have been devised, as mentioned on page 28 ; these in- 
struments are not well tolerated as a rule. Failing these, re- 
sort should be had to the method of securing retraction of the 
palate suggested bj^ Dr. Wales, as mentioned on page 29. 
Open access having thus been obtained to the upper pharynx, 
applications may be easily made by the probe, brush, sponge, 
or spray. The use of the spray of course requires' that the 
palate should be retracted or relaxed, while the other methods 
of application are available even if the palate is drawn up, the 
instrument being crowded through the contracted opening, 
though of course in this procedure more or less of the fluid is 
liable to be pressed out and trickle down the pharynx into the 
larynx. 

The steam atomizer. — This is a rather ingenious and attrac- 
tive little instrument, in which an atomizer on the principle 
of the Bergson tubes is worked by the action of steam. This 
plan was first suggested by Dr. Siegle, of Stuttgart. Fig. 'o'o 
illustrates the ordinary form in which the device is made use 
of. The steam atomizer is undoubtedly of much value in many 
of the catarrhal affections of the upper air-passages, if proi^er- 
ly used. It is also without question an instrument of mischief 
if imjn'operly used. As the rule, it should never be used in 
chronic catarrhal inflammation, as the hot steam has a tendency 



62 



METHODS OF TREATING MUCOUS MEMBRANES. 



to produce relaxation and congestion of the parts. In acnte 
inflammatory affections, on the other hand, it serves oftentimes a 
most excellent purpose, as in acute and subacute laryngitis ; 
acute tonsillitis, etc. The method of using the instrument is 
of conrse obvious. 

InhaJations. — This method of treating mucous membranes 
consists in the utilization of the principle that certain drugs 
give off their volatile element under the action of hot water, 




Fig. 60. — The steam atomizer after the principle of Siegle. 



and that this volatile agent may be carried directly to the dis- 
eased surface by inhaling the vapor of the hot water impreg- 
nated with the agent. Among the remedies used in this man- 
ner are, lupulin, benzoin, ol. picis, creasote, carbolic acid, opium, 
hj^oscyamus, etc. This method is also valuable in acute affec- 
tions, but as a rule should not be used in chronic inflammation. 
A simple method of carrying out this plan of treatment is to 
place a small amount of the drug to be used in an open-mouthed 
bottle, or a tea-cup, and add a portion of hot water at a tem- 
perature of not less than 160°. The cup is then held under the 
mouth, and the medicated vapor inhaled. A number of instru- 
ments have been devised for the more elaborate carrying out of 
this plan of procedure, the most complete one being Macken- 



/S 



Tt/ 



MAKING APPLICATIOlSrS. 63 

zie's inhaler, shown in Fig. 67. This instrument is described by 
Mackenzie as follows : 

"The inhaler consists of three parts, «, &, and c. a is an 
open vase, and is essentially the containing vessel into which 
the hot water and medicated solution are put. It is shown in 
A, with a pint of water in it, and above the water-line is a 
large space for steam ; & is a kind of lid resembling an inverted 
tumbler, which forms the cover of the containing vase. It is 
seen in its proper position in «, and with the sides of the vase 
drawn diagramatically in h. The bottom of the tumbler forms 
the covering of the vase, 
and the sides of the tumbler 
dip down into it, leaving an 
air chamber between the ^ | 
two parts. When the vase "^ ^ 
contains the proper quan- ^ 

tity of water, the sides of ^"^ ^ ' ' 'l\ « 

the inverted tumbler or lid /-"- °° °-^| 

dip down only about half i-~= 
an inch below the water- Vj-f:-;-^!- 
line. The circumference of '^"Vjo \ 

the lid is perforated with J. P '*i^=^- 

small holes, as seen in x, ^K:f_^__-^^^ "" ^""^"^ 
and the circumference of 
what would be the rim of 
the tumbler is perforated in the same way at z. The ajDertures, 
both above and below, communicate with the air chamber. 
When the patient inhales, air rushes through the various holes 
above at x, then through the air chamber, again through the 
series of holes at z, and finally up to the mouth-piece, as shown 
by the course of the arrows. In the centre of the upper surface 
of the lid is a projecting nozzle, to which is attached a flexible 
tube, provided at its extremity with a double-valve earthen- 
ware mouth-piece. There is an opening in the lid through which 
a thermometer registering high temperature passes into the 
water, c is a stand on which the vase rests, and is made hol- 
low to receive a spirit-lamp." 

As will be seen, in this instrument, the air which is inhaled is 
made to ti-averse the medicated solution, and thereby becomes 
more thoroughly impregnated with its volatile elements than is 
the casein the simple device of the cup or open-mouthed bottle. 



-Mackenzie s eclectic inhaler 



CHAPTER IV. 

TAiaNG COLD. 

Although this is one of the commonest and most familiar 
of plienomena, both as a matter of clinical observation and of 
personal experience, if we ask ourselves what especial influ- 
ences produces the morbid changes which we call taking cold, 
or what is the true relation between the recognized cause and 
observed effect, we find it somewhat difficult to give a correct 
answer to the question. 

Among the numerous theories advanced may be mentioned 
that of Rosenthal. His theory is that the immediate effect of 
cold acting on the surface of the body is to excite contraction 
in the peripheral vessels by which the blood is driven from 
the surface in upon the internal organs, and acts there as an 
irritant, exciting inllammation. This view of the matter is 
somewhat mechanical, and scarcely explains the action of cold 
in many instances. Not infrequently, as the result of an expo- 
sure, it is not really internal organs that become the seat of 
the consequent intiammation, as an attack of acute eczema, or 
acute conjunctivitis, may follow ; or in the case of the common- 
est of all intlammatory affections resulting from exposure, an 
attack of acute coryza affects a membrane so near the surface 
that under the action of Rosenthal's theory the blood should 
to an extent at least be driven fiom the membrane rather than 
that it should be flushed upon it from without. Furthermore, 
as we know, mere mechanical congestion does not lead to true 
inflammatory action, as shown by the old familiar and often 
repeated experiment of ligating the efferent veins of the frog's 
foot, and observing the result in the web under the microscope. 

A far more plausible view of the matter is that of Seitz. 
His theory is that disorders resulting from catching cold are 
due to the removal of heat to an unusual extent from the ex- 
ternal or internal surface of the body ; that this causes some 



TAKING COLD. 65 

functional disturbance, which in its turn gives rise to certain 
morbid processes distant from the part immediately affected 
by the cold. That the morbid changes are not due to the imme- 
diate or direct effect of this exposure, is evident from the fact 
that, as a rule, a certain length of time elapses before these 
changes set in! 

The theory of Seitz, it seems to me, is not comjDlete, but 
leaves the matter still somewhat in the dark. The true action 
of cold upon the body in producing morbid conditions is prob- 
ably on those nutritive changes which are constantly going 
on, and by which the animal heat is developed. This heat- 
production is going on in all the tissues of the body. In order 
that this function shall not be impaired, it is necessary that 
the normal temperature shall be maintained. This we know 
is 98|-°. Any marked deviation from this normal standard, as 
the result of extraneous influences, results in morbid changes. 
If heat-production is arrested in a portion of the body under 
the action of an intense cold, molecular death of the part 
ensues, as is the case when gangrene of a limb results from 
freezing. If the action of the cold is insufficient to arrest the 
nutritive processes of the part, it may cause only inflammatory 
action. In these cases we have only the direct action of a low 
temperature on the organism. In the ordinary phenomena of 
"taking cold," we have still the result of a low temperature 
acting on the heat-producing processes, but in an indirect 
manner. The direct action of the cold is, as a rule, upon the 
surface of tlie body, but the resultant morbid condition is 
upon some organ remote from the exposed xDart. In both 
cases, however, the cause and effect are the same, and the con- 
nection between the exposure and resultant inflammatory con- 
dition is the disturbance of those nutritive changes in the 
tissues which result in the jDroduction of animal heat. 

There are three factors generally necessary for tlie produc- 
tion of "a cold : " low temj^erature, air in motion, and moist- 
ure. It is also necessary as a rule tliat one or more of these 
factors should act for a somewhat prolonged duration of time. 
As we know, the momentary action of an intense cold or draft 
or moist atmosphere does not usually result in any morbid 
changes, but it is only after a somewhat prolonged exposure 
of the body that the familiar phenomena of a cold ensue. 
In our ordinary life there are few of us but that are subject 



66 TAKING COLD. 

to sliglit temporary exposures with impunity ; as for instance, 
upon rising in the morning in a cold room, clianging one's 
clothes, etc. On the other hand, the sitting in a draft for a 
prolonged period, with even only a small portion of the body 
exposed, may lead to serious or grave morbid changes. Among 
the most familiar causes of taking cold may be enumerated, 
sitting in a draft, wearing insufRcient clothing, wearing thin- 
soled shoes, insufficiently protected feet, going from a warm 
room to a cold room, slight exposure while perspiring, etc. 
Wearing thin-soled shoes, or insufficiently protected feet, is a 
very prolific source of trouble ; as the loss of heat in this man- 
ner is far greater than is usually recognized. Especially is this 
the case if the soles of the shoes are damp, as in this case of 
course the radiation takes place much more rapidly. 

Again, when the body is perspiring, the loss of heat is going 
on with considerable activity ; hence we find that in this condi- 
tion even a slight exposure is liable to result in far more se- 
rious disturbance than would occur from the same exposure 
were the body not in an overheated condition. There should, 
however, be borne in mind this difference, if the perspiration 
is the result of violent exercise, all the nutritive processes are 
stimulated to an abnormal activity, animal heat is being gener- 
ated rapidly, and the perspiration necessarily sets in as a con- 
servative measure, to prevent too great accumulation of heat in 
the system, but still as the direct consequence of the violent 
exercise. If now in this condition the body is exposed to the 
influence of cold, and the perspiration suddenly checked, very 
serions consequences may ensue. If, however, on the other 
hand, a copious perspiration is brought on by artificial means, 
while the bod}^ is in a state of quiescence, as in the hot room 
of the Turkish bath, the heat source is from without, the heat- 
producing forces of the system are not disturbed, and the cold 
plunge, while of course it suddenly checks the perspiration, 
does not, as a rule, give rise to any untoward consequences. 
Moreover, the exposure by the cold plunge is only temporar}'^ 
and of short duration, and by the subsequent manipulation, 
any serious loss of heat which may have resulted is speedily 
and completely restored. 

A swimmer will remain in water at a temperature twenty 
or thirty degrees below that of the body, and that too for a 
somewhat prolonged period of time ; but while in the wa- 



TAKIIN'G COLD. 67 

ter lie is in a state of constant and often laborious activity, 
thereby setting in play those processes by which animal heat 
is generated. But even with this constant activity, if the bath 
becomes too prolonged, there conies a time when the body is 
unequal to the task of supplying sufficient animal heat to make 
up for the loss, and the bather succumbs to the direct influence 
of this tremendous drain upon the system. As was said before, 
the loss of animal heat does not directly produce these morbid 
changes, but creates or gives rise to certain functional disturb- 
ances, with the nature of which we are not entirely acquainted, 
and these give rise, after a certain interval of time, to the mor- 
bid changes which we call taking cold. This interval may be 
sliort, lasting perhaps but a few hours, as is usually the case 
in slighter disorders, or it may be prolonged one or two days, 
or even more. In this case, as a rule, the resultant disorders are 
of a more serious character. There is generally attendant 
upon taking cold, fever of a more or less marked character. 
That this fever is not symptomatic, but an essential fever, is 
shown by the fact that it stands in no constant relation to 
the morbid changes which result, as in even slight disorders 
we may have the febrile motion more marked than the fever 
which accompanies the more aggravated forms of intiammatory 
troubles which may arise from the cold. Moreover, the fever 
generally sets in immediately after exposure, and when the 
later morbid changes appear, no increase of fever, as a rule, is 
detected. As regards the local disorders, which result from an 
exposure to cold, we find them manifesting themselves in any 
part of the body. We may have acute coryza, pharyngitis, 
gastric catarrh, muscular rheumatism, cystitis, or, in fact, an 
attack of inliammation involving any of the organs of the body 
as the result of a cold. Owing to their exposed situation, be- 
ing the first to receive the current of inspired air with its im- 
])urities, or whatever of irritating qualities it may possess, the 
upper air-passages are perhaps more subject to inflammation 
than any other portion of the bod}^, and once having become 
the seat of morbid changes there is always a liability to a recur- 
rence of the attack from a sligliter exciting cause than that 
which gave rise to the first attack. 

Hence, it is probable that catching cold, in a very large ma- 
jority of cases, develops in an attack of acute inflammation of 
some portion of the upper air-passages, as being the point of 



68 TAKING COLD. 

least resistance, and, further, as tliese attacks recur witli in- 
creased frequency and gravity, we find that the morbid process 
localizes itself farther down and nearer to the vital centres, and 
finally this liability, so called, to take cold, which at first mani- 
fested itself in attacks of simple coryza, or sore throat, gives 
rise to a bronchitis or some still graver affection which fixing 
itself upon the lungs may prove far less amenable to treatment 
than the simpler attacks which preceded it, or even lead to the 
development of those still graver forms of pulmonary disease 
in the management of which our present therapeutic resources 
are so feeble. 

The question is often put to the physician whether a ca- 
tarrh will lead to the eventual development of lung disorders ; 
and it seems to me that the answer should be that it may, and 
that it often does, in the manner above noticed. 

This may not occur by absolute extension of the inflamma- 
tory process, but there can be no question that an individual 
suffering from a chronic larjmgeal catarrh is far more liable to 
an attack of tracheitis, and that one suffering from a tracheitis 
is far more susceptible to a bronchitis than one in whom there 
exists no catarrhal inflammation, and so on down to the deeper 
lung tissues. Other causes of course may operate in inducing 
such a sequence of events, such as an impairment of the gen- 
eral health from any cause, but a prominent factor still remains 
in the existing catarrhal inflammation above. 

As regards the so-called liability to take cold, it should be 
understood that this is, in a large majority of cases, and proba- 
bly in every case, due to an existing chronic catarrhal inflam- 
mation, of perhaps so mild a tyi:)e as to give rise to but very 
trivial symptoms, or even pass unnoticed ; but still an existing 
catarrh, the result probably of a neglected cold, and the re- 
newed attacks to which the individual becomes so liable, con- 
sists in a lighting up of the old trouble. As each fresh attack 
subsides, the resolution which the inflammatory process under- 
goes is less complete, the chronic trouble makes itself known 
by more decided symptoms, fresh colds occur with greater fre- 
quency, and there is finally established a chronic catarrh, be 
it laryngeal, nasal, or of any other part, with its many annoy- 
ances, its intractability, and unquestionably the possibility of 
its leading to graver trouble lower down in the air-passages. 

Our concern of course is mainly with affections of mucous 



TAKING COLD. 69 

membranes ; but in tliose cases in wliicli we find that a cold 
gives nse to an attaclv of rlienmatism, gastric catarrh, cystitis, 
or any disorder other than a catarrh of the lining membrane of 
the respiratory tract, probably the same rule holds true as 
before ; from some inherited tendency, or acquired weakness, 
the parts involved in these affections have become the points 
of least resistance, and lience invite those morbid changes 
which result from exposure to cold. 

Pi'emntion of a cold. — The natural deduction of course from 
what has been said before is, that tliose conditions which give 
rise to a cold should be avoided ; especially should this be en- 
joined upon those possessing hereditary tendencies or weak- 
nesses, and tliose of whom we speak as liable to take cold. 
These directions of course are more important in the months of 
the year when we have, to the greatest extent, the prevalence 
of those conditions which, as we have seen, are concerned in the 
production of a cold : as low temperature, moisture, and air in 
motion ; this we find in Spring and Fall. Perhaps the most im- 
portant direction that can be given in regard to preventing 
colds is in the proper regulation of the clothing. The body 
should be clothed sufficiently for warmth and comfort, no less 
and no more. If too little clothing is worn there will necessa- 
rily result a loss of animal heat. If too much is worn the body 
becomes overheated and perspiration necessarily ensues to re- 
duce the temperature and restore the proper equilibrium, and 
consequently, as we have before seen, a condition arises in 
which the body is extremely sensitive, and in which it is espe- 
cially liable to succumb to the influence of cold or moisture. 
This rule in regard to clothing the body applies to all parts of 
it. The mistake should always be avoided of coddling any 
portion, or of leaving any i)ortion insufficiently protected. A 
very frequent and common error is fallen into by many, of 
crowding on too much clothing upon those portions of the 
body which they suppose to be subject to some special weak- 
ness ; as for instance, many people supi.)Osing themselves to 
have weak lungs or throats, fall into the error of piling wrap 
upon wrap, muffler upon muffler, around their necks and about 
their chests, thereby encouraging the very condition wliicli thej'^ 
fear, and incurring the risk they desire to avoid ; for the exces- 
sive muffling of the parts necessarily leads to perspii-ation, and 
consequently the danger of its sudden checking upon the re- 



70 TAKING COLD. 

iiioval of tlie wraps. I know of no more prevalent mistake, nor 
one which is a more prolilic source of mischief, than tlie habit 
which ptrevails to so great an extent among us, of muffling up 
the neck. Especially is this the case when a cold is contracted 
which develops in a sore throat. As a rule, when a sore throat 
comes on, the very first remedy which is adopted is to tie a 
dirty red flannel about the neck. The only advantage of tliis 
procedure lies in a certain amount of counter-irritation due to 
the harsh fibre of the fiannel rubbing against the skin. Aside 
from this, there is no possible good to be accomplished. It is 
put on for a protection, it simply renders the neck and throat 
more sensitive, and entails a greater liabilit}^ to take another 
cold. Of course what is said about the neck may l:)e said about 
any other portion of the body. Excessive covering should be 
avoided under all circumstances. This perhaps is a greater 
error than insufficient protection, although the latter is un- 
doubtedly a frequent source of trouble. This ma}^ be said per- 
haps in regard to the feet quite as much as of any other part 
of the body, for coming in contact as they do with cold fioors 
and pavements, especially when there is water or moisture on 
the ground, the loss of heat from the general system from that 
source is necessarily rapid, unless the foot is thoroughly well 
protected by a thick, dry sole to the boot. There are few but 
have experienced the direct pflect of standing in slippers or 
thin-soled shoes upon a damp or cold pavement, and noted the 
rapidity with which such exposure makes itself felt. In our 
climate, with its sudden and marked changes of temperature, 
the proper regulation of the clothing becomes a matter of con- 
siderable importance, and perhaps of no little difficulty. The 
hands and face are larel}' covered, as a rule, or protected, and 
yet we never take cold from their exposure. The deduction is 
obvious; if certain parts of the bod}^ may be exposed with im- 
punity, the converse conclusion is suggested, that by keeping oui- 
bodies too warmly clad we have thereby engendered a necessity 
which possibly might have been avoided, with benefit to the 
health and vigor of the system. The rule maybe safely laid down, 
that, in clothing the bod}^ the trunk and limbs should be made 
simply comfortable, but never wrapped to the extent of indu- 
cing perspiration by the amount of clothing. The foot should 
be covered with a boot or shoe, with a sole sufficiently thick 
to prevent the cold or dampness of the pavement being felt 



TAKING COLD. 71 

tlirougli it. The neck slioiild never be muffled, or covered with 
thicli wraps or furs, unless rendered necessary by the piercing 
winds or cold of midwinter, as a mere matter of comfort. The 
head is endowed by nature with its own protection ; hats and 
caps aj-e luxuries born of modern civilization ; had they never 
been worn, mankind would be better off and the demand for 
hair restorers would never probably have existed. Hats and 
caps, however, being a necessity of modern life, should be 
light, well ventilated, and designed to retain as little heat as 
possible ; they should not be too heavy or press with too much 
weight upon the head, the crown should be perforated to allow 
of as free circulation of air as possible between the top of the 
head and crown of the hat, and should be constructed of such 
material as will allow of the escape of heat. 

The hair, the natural covering of the head should, be so 
regulated as to avoid the exposure resulting from the removal 
of a considerable amount at one time by cutting ; if it possesses 
a luxurious growth, it should not be cut when the removal of 
so much jDrotection of the head is liable to result in catching 
cold. 

In short, the body in all its parts should be made comforta- 
ble. It should not be so clothed as to cause perspiration, nor 
that cliilling can occur. It is said that seal-skin sacques have 
caused more deaths than small-pox in New York in the last 
five years. I have no doubt that this is quite true, and the 
fact is due simply to the vanity or indolence by which a wo- 
man will go from the cold air into a warm room, with her 
sacque on, and remain there for hours, it may be,^ without re- 
moving it. In addition, it might be said that very much harm 
is done by the liabit of wearing heavy clothing, and sitting in 
overheated rooms. Those who allow themselves to grow into 
the habit, by which they are only comfortable in a room at 80°, 
are simpl}^ making hot-house plants of themselves, and are en- 
gendering a condition of the system wliich renders its resisting 
power very feeble. It is purely a habit, and one easily over- 
come not only without risk but with undoubted benefit to the 
individual in the increased vigor of body which will result. 

These suggestions are, of course, such as every physician is 
familiar with ; they are given here, however, more in the way 
of suggestions than for insti'uction, for we are far too prone to 
overlook and forget them in our dealings with our patients, 



72 TAKING COLD. 

and allow tliem often to violate, tlirongli ignorance, simple 
laws of well living, wliose observance might save them much 
suffering. 

Treatment of a cold. — It is very much to be deprecated 
that as a rule an ordinary cold is allowed to take its own 
course without treatment. If a part has once become inflamed, 
and is permitted to undergo resolution without interference, it 
is left in a weakened condition which invites renewed attacks 
from a very slight cause ; for when the acute inflammator}^ pro- 
cess subsides, complete resolution does not take place, but 
there is left a morbid condition, vei-y mild in character per- 
haps, but nevertheless one of chronic inflammation. This may 
be so slight as to be scarcely noticeable by the patient, and yet 
it is this condition which takes on a renewed inflammation 
from a very slight provoking cause, which oftentimes the pa- 
tient would escape did it not exist. The ordinary plan of 
treatment of a cold is so simple and involves so little trouble, 
that it is the dut}^ of the physician to urge that all cases, how- 
ever simple, should be subjected to it. 

Remembering the causes, as laid down above, which oj)er- 
ate in the production of a cold, the first indication for treat- 
ment will be to supply as promptly as possible the deficiency 
caused by this loss of bodily heat. If this can be done in the 
early stages, when the secondary inflammatory process has not 
progressed, or better still, before it has set in, viz., during the 
preliminary febrile stage, the further progress of the disorder 
may be promptly arrested ; this constitutes what we generally 
call the abortive plan of treatment. This plan consists, in 
short, of producing copious perspiration ; this perspiration, be 
it remembered, however, is not primarily the object it is de- 
sired to attain, but it is simply the evidence that that object 
has been attained. The condition to be corrected is loss of 
bodily heat ; the measures resorted to for this are measures 
which have a tendency to increase bodily heat. The evidence 
that this has been accomplished, viz., the restoration of this 
heat, or even more, that an excessive heat is produced, is mani- 
fested by the perspiration. If this so-called sweating can be 
brought on in the early stage it serves the purpose of arresting 
the future progress of the trouble, and putting an end to the in- 
flammator}^ process. If it can be brought about early in the 
progress of the inflammatory stage its gravity can be very ma- 



TAKING COLD. 73 

terially lessened ; lience, tlie earlier tins abortive treatment is 
resorted to, the better the result. The means of accomplishing 
this is by simple remedies familiar to all. 

A decoction of hot tea taken at bed- time, with the addition 
of a foot-bath and a moderate dose of Dover's powder, is all 
that is necessary ; after which the body should be warmly cov- 
ered in bed and extreme care exercised to prevent any expos- 
ure while the perspiration is going on. If the constitutional 
symptoms assume a graver form, that is if the fever seems ex- 
cessive and the effect on the general system marked, much 
benefit in addition will be gained by the administration of ten 
grains of quinine in connection with the diaphoresis. It is gen- 
erally asserted that following a copious perspiration there is 
danger of contracting additional cold on leaving the bed in the 
morning. This probably is a mistake, although the simple pre- 
caution should always be taken of allowing the body to cool 
off gradually before rising, by removing a portion, at a time, of 
the bed covering and also remaining indoors for a few hours 
after dressing. If, as the result of this treatment all symptoms 
disappear*, little else is needed except the exercise of ordinary 
precaution. 

If, however, the inflammatory stage has set in, and the re- 
sult of the sweat has been simply to modify and not to remove 
it, other measures should be resorted to, directed to the special 
locality of the inflammation. The remedies indicated will be 
referred to when we come to treat of special diseases. Confine- 
ment to the house should be urged in all cases, as of equal, 
if not of greater importance than therapeutic measures, espe- 
cially if the inflammatory condition shows au}^ possible grave 
tendencies. 



DISEASES OF THE FAUCES. 



CHAPTER V 



CATAEKHAL AFFECTIONS OF THE PHAEYNX. 

The use of tlie term fauces has been criticised as being in- 
definite and as referring to no specific region of the body. It 
is adopted here, however, in tlie absence of any better term, to 
describe the back part of the mouth and lower pharynx. This 
includes the soft palate, uvula, pillars of the fauces, tonsils, and 
that portion of the pharynx wdiicli is visible by direct inspec- 
tion. To avoid confusion as to terms, it may be well here to 
define the anatomical relations of the parts to be treated, and 
to make plain what specific regions it is intended to designate 
when the different terms are used. 

The 2y7iarynx.— This term properly refers to all that region 
which is situated between the nasal cavities, the mouth, and the 
larynx. It is bounded anteriorly by the posterior nares and 
mouth, above by the base of the skull, below by the larynx 
and oesophagus, posteriorly by the cervical vertebra, and later- 
ally it lies upon the important blood-vessels and nerves of the 
neck, and is connected by the Eustachian tube with the inter- 
nal ear. It is a somewhat conical-shaped cavity, broader above 
than below, about four and a half inches in length, lined with 
mucous membrane somewdiat closely attached posteriorly to 
the vertebra, and loosely attached to other portions. Properly 
speaking it comprises two cavities, and in the use of terms in 
what will be said hereafter, that portion which is above the 
free border of the palate will be spoken of as the upper pharynx 
or the vault of the pharynx ; while on the other hand, w^hen the 
term pharynx or lower pharynx is used, it should be under- 



ANATOMY AND PHYSIOLOGY. 



75 



stood to refer to that portion which is visible on direct inspec- 
tion, viz., that portion below the border of the palate. 

The upper pliarynx or 'oault of the pharynx is lined with 




Fig. fiS. — Anterior view of tlie innso'cK of tti( i)h u\n\ iiml inlito after removal of tlio tontiue, liyoid 
bone, and larynx as far as the posterior scgMU nt of ttu ttij loid ( artilige (Luschka) : A, aponeurosis of the 
soft palate : H, thyroid portion of the p \\ ito ph irj ngcnh muscle , C, arch-like connection of the levator- 
palati muscle; D, Azygos uvula : I, G bundle of consti ittors in posti rior wall of pharynx; H, pharyn- 
geal pfjrtlon, and K, palatine portion of pdato phaijngeus muscle, L, G'osso-pharyngeus muscle; M, 
hyo-pluiryngeus rniiscle ; N, posterior stgrnent of Ihyioid caitilagc , 1, aponeurosis of the thyro-pharyngo- 
jialatine muscle, below which are the longitudinal fibres of the oesophagus springing from it. (Cohen.) 



mucous membrane covered b}' columnar ciliated ejjilliclium, 
and is very richly endowed with glands, which are in this re- 



gion mostly of the com2)ound racemose variety. 



These glands 



76 



DISEASES OF THE FAUCES. 



aie aggregated to such an extent as to give it the name of the 
pharyngeal tonsil. They secrete an abundant mucus, which is 
poured out upon the membrane and serves to keep it in a soft, 
moist, and pliable condition. It is also squeezed out as it were 
in the act of deglutition, and serves to coat the bolus of food, 
thus facilitating its passage down the oesophagus. 

The %)liarynx proiDer, or lower pliarynx^ viz., that portion 
below the border of the palate, is lined with mucous membrane 
more closely adherent to the parts than that of the upper 
pharynx. It is covered with squamous epithelium and is en- 
dowed with simple and compound follicular glands, somewhat 
sparsely scattered through the membrane. 

The soft palate is a movable fold of membrane which is sus- 
pended from the posterior border of the hard palate. It contains 

a number of muscles by which 
it is acted upon, and is endow- 
ed with certain functions in con- 
nection with articulation and 
phonation, and also in the act 
of deglutition. With its ac- 
tion in the formation of the 
voice we need not concern our- 
selves further than to say that 
by its position, in partially or 
completely closing the nasal 
cavity posteriorly, it modifies 
the character of the voice, giv- 
ing it or depriving it of its na- 
sal tone. 

In deglutition the palate is 
drawn firmly backward and 
upward against the posterior 
wall of the pharynx, complete- 
ly closing the opening between 
the mouth and posterior nares, 
thus preventing the entrance of 
the bolus into the nasal cavit}^ 
This is mainly accomplished by the contraction of the palato- 
pharyngeus muscle, which forms almost a complete circular 
muscle resembling the orbicularis. This is shown in Fig. 68, 
which illustrates the distribution of muscles on the under sur- 




Fk e*)— Ante 11(1 
ipace I- a one side the 



maeil 
s b en 
di'^sected awa\ (afLei Ln=chl i) 1 Riptum 2 
middle 3 lower turbinated bone 4 tubero^itj 
ol the pharyngeal orifice of the Eustachian tube; 
5, soft palate ; ti, uvula ; 7, stylo-pharyn.g-eus mus- 
cle; 8, levator-palati ; 9, palato-pharyiigeus mus- 
cle. (Ziemssen. ) 



ACUTE CATAERHAL PHARYNGITIS. 77 

face of the palate and on the wall of the pharynx. Fig. 69 
shows the muscular distribution on the upper or nasal face of 
the jDalate. 

riiysiology. — The pharynx serves as a vestibule of commu- 
nication between the nasal cavity, the mouth, the larynx, and 
the oefc.ophagus. Its prominent function is in the act of degluti- 
tion. In this act the bolus of food is passed by the tongue 
toward the-back of the oral cavity until it passes the palato- 
glossi muscles which form the anterior pillars of the fauces. 
Contraction of these muscles ensues b}^ which the mass is pre- 
vented from re-entering the mouth. At almost the same time 
the palate is raised by the action of the levator palati, and the 
palato-^Dharyngei muscles which form the posterior pillars of 
the fauces contract and thereby close the opening into the 
vault of the pharynx, by which the mass is prevented from en- 
tering the nasal cavity. The larynx is next drawn up under 
the base of the tongue by the action of the digastric, mylo- 
hyoid and genio-hyoid muscles. By this movement the epiglot- 
tis falls upon and covers the rima glottidis, thus preventing the 
food from making its way into the air-passages. The bolus now 
makes its way over the anterior surface of the epiglottis, and 
passes from the control of the voluntary into that of the invol- 
untary muscles of the jDharynx, which is raised by the additional 
aid of the j^alato-pharyngei and stylo-pharyngei muscles to 
receive it, the constrictor muscles of the pharynx passing it on 
to the oesophagus. 



Acute Catarrhal Pharyjstgitis, or Ordinary Sore Throat. 

This is an acute inflammation of the mucous membrane 
lining the lower ^oharynx, which often extends to the soft 
palate, uvula, tonsils, and pillars of the fauces. It is usually 
moderate in character and limited in duration, and is the affec- 
tion ordinarily designated as common sore throat, altliough 
this term is often api)lied to tonsillitis, laryngitis, and, indeed, 
to many of the milder inflammatory affections of the fauces. 

It ma}^ be of so mild and trivial a character as to be attended 
with very little pain and discomfort, and accompanied with no 
symptomatic fever. In the more aggravated form, liowever, it 
may be ushered in by a cliill, or chilly sensations, followed by 



78 DISEASES OF THE FAUCES. 

an active febrile motion. It may be confined to the lower pha- 
rynx alone, or it may extend to the pillars of the fauces, soft 
palate, uvula, and tonsils. In the majority of cases it is the 
result of taking cold, though, occasionally, it may be the re- 
sult of direct injury, irritation from the inhalation of noxious 
vapors, an impure atmosphere, etc. 

Symptoms. — If the attack is moderate in character, the 
attendant symptoms consist mainly in a mere sense of discom- 
fort about the throat, with some little excess of secretion, and 
possibly slight pain in swallowing. In the severer cases, how- 
ever, attended with an active inflammation of the mucous mem- 
brane, extending well forward on the palate, uvula, and tonsils, 
we find a considerable extent of swelling of the parts, with a 
tendency to oedema manifesting itself most markedly in the 
uvula, together with some swelling of the tonsils. In these 
cases, therefore, the symptoms become more decided, swallow- 
ing is painful, as the result of pressure on the diseased mem- 
brane, and difficult, from the fact that the muscles involved in 
the act are somewhat afl'ected, especially the muscles compos- 
ing the pillars of the fauces. The muscles are not inflamed, 
but they are liable to become the seat of a moderate degree 
of serous infiltration as the result of the activity of the infiam- 
matory process involving the membrane covering them, thereby 
interfering with the proper performance of their function. The 
voice is apt to be somewhat thick and husky, with a decidedly 
metallic tone, due partially to a sympathetic irritation of the 
larynx, and partially to the fact that the inflamed pharyngeal 
surface fails somewhat in its proper function in acting as a 
sounding-board against which the vocal waves flrst strike on 
issuing from the larynx. 

The general symptoms attending the affection may consist 
in a more or less well-marked febrile motion, manifested by an 
increased frequency of pulae, heat of skin, and rise in tempera- 
ture to 101° or 102°, anorexia, etc., or there may be simply a 
feeling of general malaise, with loss of appetite and headache. 
Cough, as a rule, is absent, but there is a tendency to a hacking, 
or an effort to clear the throat from the accumulation of mucus. 

Examination. — If seen in the earl}^ stage the mucous mem- 
brane, as far as the inflammatory process extends, presents a 
congested appearance more or less well marked, according to 
the severity of the attack ; varying from a deep rose color to a 



ACUTE CATAERHAL PHAEYNGITI3. 79 

dark angi^ -looking red. At the first onset of the attack the 
secretion is somewhat scanty or entirely suppressed, the mem- 
brane presenting a dry and glazed appearance ; as the disease 
progresses, however, a more or less profuse mucous or muco- 
purulent discharge sets in, and will be noticed covering and 
adhering to the parts. If the attack is an aggravated one, the 
membrane will be seen presenting a decidedly swollen and 
(Edematous appearance. This will be especially marked in 
those parts where it is loosely attached, or where it lies upon 
loose areolar tissue beneath. This condition exists in the 
uvula to a greater extent than elsewhere, hence this organ is 
often markedly swollen and presents a humid and watery ap- 
pearance. 

The tonsils may be so far involved in the inflammatory pro- 
cess as to be raised somewhat from their bed, and to project 
fi'om between the pillars of the fauces ; the membrane cover- 
ing them, however, presents the same congested color as that of 
the other portions of the fauces involved. The soft palate in 
these severer forms of sore throat is usually affected as far as its 
junction with the hard palate, from which point the congested 
color of the membrane shades gradually into the healthy tissue 
beyond. 

The diagnosis is easily made in so simple an affection as 
this. It may be confounded with subacute tonsillitis or a folli- 
cular tonsillitis. In the first case, as a rule, the tonsil stands 
out prominently, and the inflammation of the mucous mem- 
brane surrounding it is limited in extent, and there is also the 
absence of the inflammation extending to the soft palate. 
Follicular tonsillitis may easily escape detection, unless a care- 
ful inspection be made, which will always, however, reveal the 
characteristic pearl-white exudation, showing itself at the 
mouths of the cr3'pts of the tonsils. 

Treatment. — The affection is not a grave one, but yet is one 
that may give rise to no little annoyance, and even suffering. 
If let alone its tendency is to undergo resolution in the course 
of a few days ; still the same assertion holds good here that 
has been made before in regard to neglected cokls ; complete 
resolution does not, as a rule, take place, but there is left behind 
a certain amount of chronic inflammation of the membrane, 
which, although of a very trivial character, and giving rise to 
very slight symptoms, is still sufficient to involve a tendency 



80 DISEASES OF THE B^AUCES. 

to a frequent recurrence of the attack. It is a matter of some 
little moment to the patient that this total restoration should 
be favored by certain simple measures which easily accomplish 
the object. 

This is an aifection in which the use of a gargle, provided it 
is properly managed, will prove an efficient method for reach- 
ing the diseased part. As ordinarily done, gargling fails to 
reach the diseased surfaces ; the patient taking a mouthful of 
fluid throws the head back, causing the fluid to gravitate 
toward the base of the tongue, wliich is raised against the soft 
palate, thus completely shutting off the posterior wall of the 
pharynx ; at tiie same time he allows a feeble current of air to 
escape through the fluid, giving rise to the peculiar gurgling 
sound ; as will be seen, the fluid reaches no farther than the 
soft palate. A little training will enable one to allow the fluid 
to reach back to the pharyngeal wall. The j^i'oper method of 
gargling is to take the fluid into the mouth, throw the head 
back, and to commence the process of swallowing it ; arresting 
the act, however, just at the point where the voluntary muscles 
act ; that is the patient should attempt to swallow the fluid, 
but should stop before the act is complete, and at a point 
where it is possible for him to expel it again. 

In going through with this procedure it will be found that 
the fluid can easily be allowed to pass completely into the 
pliar3^nx, and down to the point where it will come in contact 
with its posterior wall, where it may be allowed to rest for an 
instant and can be rejected without its passing into the stom- 
ach. In ordinary sore throat of a purely catarrhal character, 
we possess no remedj^ more efficient than chlorate of potash. 
This may be used in the saturated solution of 3 ss. — 3 j. 
Among other astringents which may be used are borax, 3 ss. — 1 j., 
sulphate of zinc, gr. v. — 3 j., and alum, gr. xx. — 3 j. If there is 
much relaxation of the parts, with a tendency to oedema, tan- 
nic acid, 3 ss. — 3 j. may be used, or better still, perhaps, ferric 
alum, gr. xx. — 3 j. In children who cannot be taught the use 
of a gargle, a very efficient method of administration will be 
found in the incorporation of the astringent with white sugar, 
to wliich may be added a small amount of powdered acacia, as 
follows : chlorate of potash, gr, xx. — 3 j., sacch. alba and pulv. 
acacia, aa3j. A small portion of this laid upon the tongue, 
becoming moistened with the saliva, is swallowed and comes in 



CHRONIC CATARRHAL PHARTJSTGITIS. 81 

contact with the inflamed membrane quite as efiiciently, or, per- 
haps, even more so than by a gargle. Of course in applying a 
remedy in this manner no astringent can be used which would 
exercise a deleterious effect from being taken into the stomach. 
Lozenges present a very simple and attractive method of 
treating an ordinary sore throat, and remembering that the dis- 
ease possesses no grave features, and that even the trouble in- 
volved in the use of a gargle will be sufficient to cause the pa- 
tient to neglect its use, a few astringent lozenges carried in the 
pocket, and which can be taken freely through the day, renders 
this form of medication of no little value. The ordinary chlo- 
rate of potash lozenge, made up with white sugar and sold in 
drug-stores, is an excellent form. The compressed tablets made 
by Wyeth & Co., of Philadelphia, present the additional ad- 
vantage of size and convenience of carriage, and are generally 
to be preferred ; they are supplied in the form of small disks 
of pure potash, and also in combination with borax, either of 
which forms are excellently well adapted for the relief of this 
affection. As regards other and general measures they are not 
usually indicated ; yet if there is much constitutional disturb- 
ance, as evidenced by the amount of febrile motion, a saline 
laxative should be given, together with the administration of 
small doses of aconite. If there is much pain about the cervi- 
cal region and angles of the jaw, cold compresses to the neck, 
frequently changed, will be found an efficient method of afford- 
ing relief. Perhaps no habit is more universal, especially 
among the ignorant, than that of tying flannel around the neck 
in ordinary sore throat ; it is a pernicious habit and should al- 
ways be avoided. 



Chronic Catarrhal Pharyngitis. 

This is a chronic inflammation of the mucous membrane 
lining the lower pharynx, of a catarrhal character, commen- 
cing usually with an ordinary sore throat, undergoing imper- 
fect resolution, and leaving behind it a moderate degree of 
chronic trouble as the result of repeated recurrences of the 
acute attack. There is gradually, slowly, but progressively de- 
veloped in the pharynx that morbid condition in its mucous 
lining which has been before alluded to as constituting chronfc 
6 



82 DISEASES OF THE FAUCES. 

inflammation of a catarrhal cliaracter. This consists mainly in 
certain hyperplastic changes in the deep layers of the mucous 
membrane, with alterations in its blood-vessels and perversion 
of its function. The active arterial congestion which charac- 
terizes the acute form disappears and there is substituted for it 
a condition of engorgement of the blood-vessels which seems to 
assume a venous character, giving the parts a deep red, often- 
times purplish color ; at the same time there are certain hyper- 
plastic changes in the deep layers of the membrane, consisting 
mainly in its infiltration with the normal cell-elements de- 
veloped in its meshes to an abnormal extent, together with an 
increased proliferation of the connective tissue and glandular 
structures of the tissue. As the result of these changes the 
membrane becomes thickened, and assumes a somewhat puffy 
appearance. This thickening does not present a smooth, uni- 
form surface, but is irregular; and somewhat nodular in appear- 
ance. It has a granular aspect, which gives it sometimes tlie 
name o:^ granular pharyngitis. This is an utterly meaningless 
name, and it seems to me should be abolished. The normal 
secretions are also changed, and there is poured out upon the 
surface of the membrane a thick, tenacious, ropy mucus. 

Commencing in the lower pharynx the inflammatory pro- 
cess extends often to the pillars of the fauces, .tonsils, soft pa- 
late, and uvula, giving them the same deep, congested purplish 
color. Occasionally the tonsils become somewhat thickened, 
and rise from their bed, separating widely the pillars of the 
fauces, and present a flat, roughened surface. The soft palate 
may be involved as far as its junction with the bony portion, 
but more frequently the uvula alone is involved, being swollen, 
somewhat elongated, and markedly congested. In this condi- 
tion it is liable to undergo those changes which result in so 
great an elongation as to require amputation. 

The progress of the chronic pharyngitis is marked of course 
by repeated acute attacks of ordinary sore throat. As the dis- 
ease develops under the stimulus of these repeated attacks of 
acute phar^^ngitis, or developing from the commencement as a 
chronic affection, as it occasionally does, it comes under the 
influence of certain secondary predisj)osing and aggravating in- 
fluences whose effect is to greatly increase the morbid condition. 
The use of tobacco is a habit which it is the fasliion to charge 
with having a large influence in the production and aggra- 



CHEONIC CATARRHAL PHARYNGITIS. 83 

vation of chronic pharyngitis. Smoking and chewing are, un- 
doubtedly, pernicious and uncleanly practices, but that they 
are responsible to the extent usually laid to their charge in 
influencing a throat catarrh is probably not true. Tobacco 
smoke is without question an irritant to the mucous mem- 
brane of the air-passages, especially if inhaled in a concen- 
trated form. On the other hand, it is also true that the 
mucous linings easily become inured to the action of the 
smoke, so that breathing or inhaling an atmosphere charged 
moderately with it is tolerated with impunity. Cubans are, 
perhaps, among our most inveterate smokers, and that in its 
worst form in the use of cigarettes, and yet they suffer some- 
wliat rareh^ from throat catarrhs. 

I do not wish to say that the use of tobacco may not, or 
does not, exercise an injurious influence on the throat, for it 
undoubtedly does in many cases, but that this is the result of 
the direct contact of the smoke with the membrane I regard as 
very improbable. The effect of smoking in producing gastric 
disturbance, as shown in the various forms of dyspepsia with 
which excessive smokers suffer, and this, in turn, leading to the 
aggravation of an existing pharyngeal catarrh, would seem to 
me to present the true explanation of the injurious action of the 
iiabit on the throat. And, again, the absorption of nicotine which 
necessarily takes place, as evidenced by the headache, palpita- 
tion of the heart, and muscular tremor which results from the 
excessive use of tobacco, produces a systemic condition which 
cannot but react unfavoraJ)ly on the morbid process in the 
fauces. From what has been said it will be easily understood 
that while condemning the use of tobacco as a vicious and un- 
cleanl}' habit, and asserting that its excessive use may exercise a 
very injurious influence on the throat, the idea is only intended 
to be conveyed that the pernicious influence is an indirect one, 
and not due to the contact of the smoke with the mucous lining 
of the upper air-passages. Hence, in estimating the influence 
of the habit on an existing throat-catarrh, the judgment must 
be based mainly on the evidence of the injurious action of the 
nicotine absorption, as shown by gastric disturbance or cardiac 
symjitoms. 

In addition, it may be said that the fumes of tobacco come 
in contact, to a very moderate extent, with the mucous mem- 
brane beyond the palate, and the only smoke which reached 



84 DISEASES OF THE FAUCES. 

the parts farther down is that which impregnates the atmos- 
phere w^hich the smoker breathes in common with others near 
him, or in the same room. Hence, of two persons, one smok- 
ing 'and the other not accustomed to the habit, it is probable 
that the smoker escapes with the greater impunity from the 
direct eifect of the vitiated atmosphere. I am disposed to 
reo-ard the habit of chewing as even more vicious than smoking 
inlts effect on the throat, and yet, as a rule, the tobacco chewer 
does not allow the saliva to reach beyond the mouth, hence it 
cannot be that its bad effects are the result of direct contact, 
but are rather due to the indirect effect of the nicotine absorp- 
tion which must necessarily result from the habit. 

Dyspepsia is another condition which has a deleterious in- 
fluence in markedly aggravating an existing throat catarrh. 
The intimate sympathy existing between the pharynx and 
stomach needs no demonstration, as it is a frequent matter of 
clinical observation; and from whatever cause the gastric 
trouble may exist, whether from smoking or chewing, or from 
some of the other numberless causes Avhich give rise to it, it is 
extremely liable to render prominent and aggravate the pharyn- 
geal affection ; and we not unfrequently meet with cases in 
which the most annoying and distressing throat catarrh is 
largely due to an existing dyspepsia, and in which relief can 
only be reached by the treatment of that disease. 

Intemperance is another frequent source of the affection 
under consideration ; and here also we find that the habit acts 
both directly and indirectly. In the majority of cases, prob- 
ably the troublesome j^haryngitis from which those addicted to 
drinking suffer, is due to the gastritis which so frequently re- 
sults from the use of alcohol ; and yet the direct contact of 
alcohol Avith the pharyngeal membrane cannot but exercise the 
same deleterious influence upon it that it does on the lining of 
the stomach ; hence we find that those accustomed to taking 
their liquor undiluted, very soon commence to experience 
trouble in the throat, due partially and largely to the direct 
impact of the alcohol upon the pharyngeal membrane, and 
also aggravated by the gastric catarrh which so soon results 
from this vicious habit. 

The quickness of the pharynx to sympathize with morbid 
conditions in the stomach, is still further illustrated by the fact 
that a temporary disorder in that organ, such as an attack of 



CHROlSriC CATAKEHAL PHARYNGITIS. 85 

indigestion, will often produce, for the time, a profuse secretion 
from the faucial mucous membrane, which is only relieved with 
the relief of the gastric trouble. How far our habits of eating 
and drinking may have an influence in the causation of a pharyn- 
geal catarrh is perhaps a question ; yet that this may be a fre- 
quent source of the disorder seems very plausible when we bear 
in mind how frequently the fauces are subjected to the ex- 
tremest ranges of temperature in eating and drinking, without 
any interval of rest ; and that, at the same meal, the pain 
caused by a mouthful of tea or coffee at nearly the boiling- 
point, is alleviated by taking instantly a drink of water at the 
freezing-point. 

The most frequent, perhaps, of all causes of pharyngeal 
catarrh is nasal catarrh, involving as it usually does the 
glands of the upper pharynx. This source of the disease is due 
partially, perhaps, to the extension of the inflammatory process 
from above downward, but more probably it is due to the con- 
stant secretion which is poured out from above, and passing 
over the membrane, gives rise to a constant hacking, clearing of 
the throat, expectorating, and labored efforts to relieve the 
fauces from the accumulation of mucus, which also must have 
something of a vicious influence, coating and adhering to the 
membrane, and interfering with its proper function. 

The action of nasal catarrh, in inducing or aggravating an 
existing pharyngeal catarrh, is still further manifested when 
the nasal trouble is attended with obstruction which interferes 
with free nasal respiration. As a consequence of this condition 
the breathing is carried on through the mouth, hence the 
pharynx is subjected to the action of a current of air contain- 
ing little moisture, and is therefore liable to become abnormally 
dry and parched. This is especially the case during sleep. 
The result, is either to cause an extension of the morbid con- 
dition to the pharynx, or to aggravate that already existing. 
This part of the subject, will be considered at length when we 
come to the subject of nasal catarrh, but it should be borne in 
mind in this connection that of all sources of pharyngeal 
catarrh the nasal disorder is by far the most frequent. 

The pharyngeal catarrh which so frequently accompanies 
phthisis, chronic bronchitis, asthma, and other pulmonary dis- 
eases, is simply an evidence of how a mild pharyngeal trouble 
is liable to be aggravated by any condition which acts to seri- 



86 DISEASES OF THE FAUCES. 

oiisly impair the general health; and furthermore also,, the 
close sympathy which exists between diseases located in 
different parts of the respiratory tract. 

Examination. — On direct inspection, the mucous membrane 
of the pharynx will be seen of a dark red, oftentimes verging 
on a purplish color ; this red color, however, is not a uniformly 
diffused red, but presents a somewhat mottled appearance, the 
discoloration being more marked in places. It is also covered 
by small masses of thick, tenacious mucus, which may aid in 
causing this mottled aspect. This, of course, should be removed 
before the proper estimate of the character and appearance of 
the membrane can be reached. Traversing the surface, also, 
will be seen enlarged and tortuous blood-vessels approaching 
the superficial layer of the membrane and coursing there for 
a longer or shorter distance as the case may be, and again 
dipping into the deep tissues, and disappearing from sight. 
The surface of the membrane presents a somewliat nodular 
appearance, that is, it is not a smooth and even surface, 
but is thickened throughout its whole extent, due as we 
have seen above to certain hyperplastic changes in the deep 
layers ; these deposits, however, seem to aggregate themselves 
in localities so as to give the surface of the membrane an 
irregular outline ; this appearance must not be mistaken for 
enlarged follicles, which stand out far more prominently and 
distinctly, and are more completely localized into rounded 
projections than the hj^pertrophic thickenings of catarrhal 
disease which are broader and more diffuse. The membrane 
is coated with a thick, tough, tenacious, opaque secretion, of a 
whitish color, verging on yellow, and adheres in a thin shreddy 
layer to the parts and is removed with some difficulty. 

Symptoms. — The voice is usually somewhat hoarse and 
lowered in pitch, partially due to the same causes which 
impair the voice in acute pharyngitis, that is, the sounding- 
board function of the pharynx is impaired ; but more parti- 
cularly due to a chronic laryngeal catarrh, which as a rule, ac- 
companies the pharyngeal disease ; the control of the voice is 
impaired ; the use of it becomes limited ; its register lowered ; 
it tires easily. 

Deglutition is probably impaired somewhat by the loss of 
the pliability of the membrane, also by a certain amount of 
mechanical interference with the proper action of the muscles. 



CHRONIC CATAEEHAL PHAETNGITIS. 87 

The pliability of tlie membrane of course being impaired by its 
hypertrophy, and also by the fact that it is not coated by the 
normal thin fluid mucus, but instead by a thick, ropy, semi- 
fluid discharge. The muscles are somewhat impaired in func- 
tion, as I believe all muscular structures are liable to be to a 
certain extent, which lie immediately in contact with, and be- 
neath a membrane in a state of chronic inflammation. There 
is more or less cough, occasionally, which, however, assumes 
more of the nature of an attempt to clear the throat, and there 
is some pain or sense of discomfort about the fauces, the feel- 
ing as of a foreign body lodged there, together with a raw, 
raspish feeling, oftentimes, which becomes a constant source of 
annoyance and distress ; occasionally the feeling is described as 
feather}^, or of a cobweb in the fauces. 

There is a more or less profuse secretion of mucus which 
gives rise to a constant hawking and expectorating ; especially 
is this true in the morning, after hours of sleep, during which 
the voluntary efforts at clearing the throat have been abol- 
ished, while at the same time abnormal secretion has been 
going on. As the result of this, there is a considerable accu- 
mulation in the fauces over night ; as the sufferer generally 
sleeps with his mouth open, the discharge loses much of its 
moisture, and becomes an extremely thick and tenacious mass, 
which is only dislodged after more or less violent efforts at 
hawking and coughing ; this performance oftentimes requiring 
half an hour or even more, which is a time of distress to the 
sufferer and no less so to those about him. 

Treatment. — It requires no especial demonstration to show 
that an application made to a coating of mucus which covers a 
diseased mucous membrane, expends its strength in coagulat- 
ing the mucus, and hence fails largely in exerting any effect 
on the membrane itself. The first step in treatment then 
should be the thorough cleansing the parts of the accumulated 
mucus. For this purpose the following solution from "Dobell 
on Winter Cough," may be used : 

1^. Acidi carbolici gr. xij. 

Sodffi biborat., 

Sodfe bicarb ua gr. xx. 

Glycerins) 3 j. 

Aqute ad. 3 vii j. 

M. , 



88 DISEASES OF THE FAUCES. 

Occasionally a few drops of ol. bergamot. may be added to 
disguise the carbolic acid, I know of no better cleansing solu- 
tion tlian the above, and for several years I have been accus- 
tomed to use it almost exclusively, in not only pharyngeal 
disease, but in all cases where a cleansing solution is needed. 
In the absence of the above solution there may be used any of 
the alkaline solutions ; as sodii chlorid., sodse bicarb., potas- 
sse carbonat., sodffi biborat., gr. xx. — 3]'., to which carbolic or 
salicylic acid may be added with benefit in the strength of gr. 
iij. — V. to 1 j. These may be applied by the atomizer or syringe. 
Failing to completely remove the mucous accumulations in this 
manner, they should be detached by means of a pellet of cot- 
ton wrapped on a probe, or some similar method. 

The parts being cleansed, there should be applied an as- 
tringent, preferably by means of an atomizer, for this more 
thoroughly diffuses the remedy than the brush or sponge. We 
possess no remedy so efficient in chronic inflammation in the 
pharynx, of a purely catarrhal character, as nitrate of silver ; 
and yet I know of no remedy that has been misused to such a 
mischievous extent as this. The mistake usually made is in 
using the strong solutions ; it should never be applied, in a ca- 
tarrhal affection, of a greater strength than gr. xx. — 33., and, 
as a rule, a five, or ten-grain solution will be found even more 
efiicient. Among other remedies that will be found of value 
are, in the order of efficiency, zinc chloridi, gr. iij. — x. to ^ j., 
zinci. sulphat., gr. x. — xx. to 3 j., acidi tannici, gr, x, — xl. to 
3]*., alumin. sulphat., gr. x. — xx. to 3J. These applications 
should be made two or three times weekly. If there are en- 
larged blood-vessels visible on the surface, they should be de- 
stroyed, and for this purpose no method in my experience is 
so efficient as the actual cautery. I am accustomed to use a 
small iron wire, about No. 20 (see Fig. 70), pointed at its end, 
which being heated to a red heat is bored into the continuity of 
the vessel. As the result of this, the vessel disappears in a few 
hours, and it is almost invariably followed by decided relief. 
This procedure is absolutely painless, and is far preferable to 
any other, in my experience. 

The remaining features of the treatment have reference to 
whatever complication may exist, such as nasal or laryngeal 
catarrh, dyspepsia, etc. These must necessarily be remedied 
before much can be hoped for in the removal of the pharyn- 



PHARYNGITIS SICCA. 89 

geal disease. The same, of course, may be said of any general 
and debilitating condition of the system. Gargles are of but 
little benefit, while lozenges and cough mixtures are useless, 
and even mischievous. The main reliance will be on the 
vigorous and efficient carrying out of the measures suggested. 



Phaeyngitis Sicca. 

This is a chronic inflammation of the mucous membrane of 
the pharynx, characterized by a scanty secretion, which dry- 
ing rapidly upon the surface of the membrane, gives rise to a 
peculiar dry, parchment -like condition. It will be remembered, 
in what was said in regard to mucous membranes in general, it 
was stated that the secretion which was poured out on the sur- 
face had its source largely in the glands and follicles, and that 
among the morbid changes which occur we meet with a condi- 
tion in which the glandular structures are destroyed. This is 
the condition which obtains in what we call pharyngitis sicca. 
As the result of chronic catarrhal inflammation, the new deposit 
in the deeper meshes of the membrane so far encroaches upon 
the glandular structures as to destroy their activity, thereby 
robbing the membrane of that proper supply of mucus by 
which it is kept in a soft and pliable condition. It may occur 
early or late in the course of a chronic inflammatory process, 
it being due rather to the adventitious deposit of the inflamma- 
tory product than to the duration of the disease. It is the re- 
sult of a simple catarrhal inflammation which may assume 
from the commencement the atrophic or dry form. It is often 
caused temporarily b}^ breathing an abnormally dry atmos- 
phere, whose passage over the upper air-tract robs the lining 
membrane of its moisture, and leaves it in a dry and parched 
condition. The habitual exi:»osure to such influences is liable 
very soon to develop a permanent dry catarrh. 

I have noticed, also, that in certain occupations there is an 
especial liability to this form of catarrh ; viz., among workers 
in tobacco, house-carpenters, millers, and in general those who 
liabitually breathe an atmosphere rendered impure by con- 
taining particles of dry dust. Why this should be so I am un- 
able to explain ; it is simply a matter of observation. 

Symptoms. — The prominent and characteristic S3^mptoms of 



90 DISEASES OF THE FAUCES. 

the affection is tliat of a parched and dry condition of the 
pharynx, a feeling of a foreign body lodged there, dne not to 
any abnormal collection of mucus, but to the fact that the mem- 
brane in this dry condition loses its pliable and elastic charac- 
ter, and opposes itself like a dry, rigid plate to the movements 
of the parts. Deglutition is somewhat difficult, and to an ex- 
tent painful, on account of the bolus of food failing to meet 
with a soft, lubricated passage, but lodging against the dry, 
harsh membrane and passing it. with difficulty. These symp- 
toms, somewhat prominent at all times, are more marked al- 
w^ays in the morning, simply from the fact that the fauces have 
been exposed during the night to the passage of air, and have 
been unrelieved by the passage of saliva and the acts of eating 
and drinking which have a tendency to alleviate it somewhat 
through the day. There is generally something of a cough, 
which is harsh, dry, and irritating in character, and due to the 
fact, that, as a rule, the larynx is involved in the catarrhal 
process^ 

Examination. — On inspection the membrane of the pharynx 
presents a glazed, oftentimes glassy appearance, showing no 
evidence of any moisture upon its surface. Its color is of a 
deep red, with a tendency to a purplish tint, this discoloration 
extending to the soft palate, uvula, and pillars of the fauces. 
There may be more or less secretion coating the surface, de- 
pendent somewhat on the chronicity of the disease and the 
time at which the examination is made. If seen in the morn- 
ing, the secretion will be noticed adhering closely and tena- 
ciously to the membrane, somewhat shreddy in appearance, and, 
as a rule, discolored by tlie impurities of the inspired air which 
have lodged upon and become incorporated with it. If, as is 
usually the case, the disease extends to the vault of the pharynx, 
inspection with a rhinoscopic mirror will show somewhat the 
same appearance in that portion of the phar3nix, viz., an in- 
jected appearance of the membrane, some thickening of the 
glandular tissue, not marked, however, a dry parchment-like 
condition of the parts, with a plug of thick, viscid, dirty-look- 
ing mucus, adhering with tenacity to the membrane, and which 
is removed with extreme difficult3^ the curved forceps being 
oftentimes necessary to detach and tear it away. 

Prognosis. — T\\\^ is an essentially chronic disease, and 
oftentimes extremely obstinate in character ; still it is very 



PHARYNGITIS SICCA. 91 

difficult at times to determine, by appearances alone, how far 
or how completely the destruction of the glandular structures 
of the membrane has been accomplished. The proper estimate 
of the extent to which the process has gone is reached by the 
clinical history of the case. If the disease has not progressed 
very far, simple measures for its relief will be effectual. If 
the disease is one of long standing it will be necessary that 
the measures resorted to in order to accomplish any per- 
manent good shall be kept up for a long period. As a rule, 
however, in every case, much relief can be given to all the 
symptoms. 

Treatment. — The object of treatment is to entirel}^ free the 
membrane of its coating of dry mucus ; to open up the orifices 
of its glands, and to stimulate them in to ^such renewed activity 
as will enable them to supply the membrane with a sufficient 
amount of mucus to keep it in a moist and pliable condition, 
and at the same time to subdue the chronic inflammation of the 
mucous' membrane proper. The first indication of treatment, 
viz., the cleansing, may be accomplished by one of the solutions 
given in the appendix ; these need to be applied with consider- 
able force, in order to detach the thick coating of viscid mucus. 
For this purpose nothing is better than the post-nasal syringe 
shown in Fig. 54, its beak being turned downward in such a 
way that the solution falls directly upon the membrane. If 
the disease extends to the vault of the pliarynx, the beak of 
tlie instrument should be turned up behind the soft palate, 
and those parts washed with the solution ; this proceeding 
should be repeated until the parts are seen to be thoroughly 
cleansed. 

If this is not accomplished by the syringe it will be neces- 
sary oftentimes to use the probe wrapped with cotton, to peel 
off as it were the adherent mucus, or else, as is oftentimes ne- 
cessary, to remove it with the forceps. This same procedure 
made use of to cleanse the mucous membrane, serves the pur- 
pose also of opening up the mouths of the follicles. These 
measures having been accomplished, the next indication is the 
application of such remedies as have the effect of stimulating 
the glands and follicles into a more copious secretion of mucus. 
This stimulation of course excites an excessive discharge, but 
the result of it is permanent good to tlie membrane, in that, it 
opens up more thoroughly the orifiGes of the glands and folli- 



92 DISEASES OF THE FAUCES. 

cles, tliat it removes the imprisoned debris, and excites a dis- 
charge which carries with it a large amount of worn out epithe- 
lium, and other irritant matter which has accumulated in the 
meshes of the membrane, and in the glands, cleaning it out as 
it were, and leaving it in a condition for the better performance 
of its proper function. The excessive discharge that is excited 
by the stimulating applications is but temporary, and, quickly 
subsiding, leaves behind it a condition of the mucous mem- 
brane, as regards secretion, which for the time being is nor- 
mal and healthy ; and which, persisting for a longer time after 
each course of treatment, finally may become a permanent 
condition of health. Among the prominent remedies which 
possess stimulating properties, as topical agents, may be men- 
tioned, sanguinaria, galanga, creosote, potassii bromid., ben- 
zoin, myrrh, belladonna, iodine, etc. Of these I regard the san- 
guinaria as one of the best remedies we possess in dry catarrh. 
It should be used by preference in the form of the powder ; an 
additional permanency of action being secured by its use in 
this form. Used alone it is too painful and therefore should 
be reduced by incorporating it with some other agent as : 

^ . Pulv. sanguinaria 3 j. 

Pulv. amyli 3 iij. 

M. 

5 . Pulv. sanguinaria 3ij. 

Pulv. myrrh, 

Lycopodii aa 3 j. 

M. 

If used in the spray, in the form of the tincture, it should be 
reduced about one-half. 

Galanga only came to my notice in dry catarrh a short time 
ago, but as far as I have used it I have been much impressed 
with its efficacy. In several patients on whom I have used 
both galanga and sanguinaria, the former seemed the more 
efficacious. This drug may be used pure, in the form of the 
powder. Of the other remedies alluded to, they possess un- 
doubtedly^ valuable properties, and should be used in case of 
failure to remove the affection b\^ means of the first remedies 
suggested. 



ELO]N"GATED UVULA. 93 

In tlie form of powder, belladonna will often prove useful as 
follows : 

^. Pulv. belladonna 3j. 

Lycopodii 3 vij. 

M. 

In the form of spray it may be used of the strength of 3 ss. 
— 3j. to §j. The potass, bromid. may be used in the satu- 
rated solution, 3ij. to ij. Myrrh is feebly stimulating, and 
may be used pure. 

These powders should be applied by the powder-blower 
shown in Fig. 47, and only sufficient thrown on to form a thin 
tilm over the parts. 

In addition to local applications, such general remedies 
should be given as may be indicated, and especially is it of im- 
portance that the sufferer so guard his manner of life that he 
may not be exposed to such surroundings as may aggravate 
his disease. 

Elongated Uvula. 

As the result of repeated attacks of sore throat, or as a chronic 
affection from the beginning, we often meet with a condition of 
the uvula, in which its normal size is increased to such an extent 
that its free end rests upon the base of the tongue. This in- 
crease in size is due mainly to hypertrophy or interstitial deposit 
in the mucous membrane covering it. There may be, however, 
hypertrophy of the muscular tissue also. This hypertrophy 
results in a marked increase in the length of the uvula, and also 
in its breadth and thickness. Lying then upon the base of the 
tongue, it gives rise to certain symptoms which are oftentimes 
of an extremely distressing character. There is a sense of tick- 
ling or irritation of tlie throat, with a feeling as of a foreign 
body lying there, which excites a constant effort to get rid of 
it by hemming or hawking. Cough is often present, and not 
infrequently of an extremely persistent and distressing charac- 
ter. It is a short, barking cough, oftentimes with a hoarse, met- 
allic ring. Upon lying down, the uvula falling backward 
touches and irritates a more sensitive portion of the fauces, 
and all the symptoms are somewhat aggravated. If there is 
very marked elongation there may be excited attacks of spasm 



94 DISEASES OF THE FAUCES. 

of tlie glottis. There may be certain reflex symptoms of a spas- 
modic character excited, due not so much to the hypertrophy 
as to the temperament of the patient ; and, whereas, in one case, 
an extreme degree of elongation may excite simply a moderate 
amount of irritation, in another case a moderate degree of 
elongation may excite attacks of suffocation more or less severe 
in character or, as I have seen in more than one case, genuine 
attacks of spasmodic asthma. 

Examination. — A simple inspection of the fauces, with the 
tongue well depressed, reveals the trouble. The uvula will be 
seen of a deep red color, club-shaped in appearance, with its 
free end resting upon the tongue. It is generally more or less 
congested, with a somewhat humid and w^atery appearance 
about its border and lower end. It is only by extreme depres- 
sion of the tongue oftentimes, or by exciting the movements of 
retching, in which the palate is drawn up, and of course the 
uvula with it, that the whole length of the enlarged organ can 
be seen. 

The uvula may be somewhat enlarged in an attack of ordi- 
nary sore throat, but rarely, if ever, to the extent of produ- 
cing any symptoms due to the elongated uvula alone, unless 
there previously existed a chronic elongation ; in other words, 
an elongated uvula is an essentially chronic affection, and that 
condition which is ordinarily regarded as an acute elongation 
of the uvula should be regarded rather as an acute pharyngitis, 
in which the uvula becomes somewhat edematous, and thereby 
enlarged. This is the disease in which patients complain tliat 
" the palate is down," and present themselves to the physician 
to have it "raised." It is an ancient tradition, that this can be 
accomplished by lifting the body by a tuft of hair on top of the 
head, and it, undoubtedly, may do good by its moral effect. 

Treatment. — The local treatment of the so-called acute af- 
fection is that of acute pharyngitis, and consists in the applica- 
tion, b}^ means of sprays or gargles, of a mild astringent, as, 
ferric alum, ferri persulph., tannin, alum, zinci sulphat., etc., 
in the strength of gr. x. — xx. to 3 J. 

In the true h3^pertrophied uvula local applications are of 
somewhat doubtful efficacy ; if, though the increase in size is 
moderate in extent, benefit may be derived by applying by the 
brush glycerole of tannin, ferric alum, gr. xx. — § j., tr. iodini, 
3ij.: — 1]-i etc., as a rule, however, the only resource is in re- 



ELONGATED UVULA. 



95 



moving the redundant portion of the organ. For tliis purpose 
special instruments have been devised, as the ordinary uvula 
scissors (Fig. 70) or Sayre's uvulatome (Fig. 71), constructed on 
the principle of the guillotine. Elsberg's instrument (Fig. 72) 
is on a similar principle. All these devices are objectionable 
as complicating an extremely simple operation. And, further- 
more, if it is attempted to cut the uvula with one of these instru- 
ments, without first seizing the organ with a pair of forceps, it 




Fig. 70. — Ordinary uvula scissors. 

will be found almost impossible, for the palate is not controlla- 
ble ordinarily by the will, and upon the slightest touch it is re- 
tracted, and the seizure of the uvula rendered extremely diflficult. 
The simplest, safest, and easiest method of operating is to seize 
the extreme end of the uvula with a pair of slender forceps, 
and drawing it forward, to remove the redundant portion by 
an ordinary pair of scissors. The use of the forceps is indis- 




FiG. 71. — .Sayre's uvulatome. 
Fig. 72. — Elsborg's uvulatome. 



pensable, as it is only by this procedure that the retraction of 
the palate can be prevented. 

In cutting through the organ tlie direction of the scissors 
should be upward and backward ; in this manner a cut sur- 
face is formed which is mainly on the posterior face of the 
organ. Hence, when food is taken, tlie palate and uvula being- 
drawn back, the wound lies against the wall of the pharj^nx, 
while the bolus of food passes over the aiilciioi- face of the 



96 



DISEASES OF THE FAUCES. 



uvula, and the raw surface escapes contact from what might 
prove a source of extreme pain and irritation. (See Fig. 73.) 
After the operation the hemorrhage is slight, as a rule, and 
the wound heals kindly in the course of a few days or a week ; 



^ .,;% 




Fio. 73.— Cutting the uvula. 



but during this time the patient is liable to suffer not a little 
from the soreness in the organ. This will be less, however, if 
the cutting is done as suggested above. In addition, it should 
be suggested, a patient should avoid eating and drinking for as 
long a time as possible after the operation, thus enabling the 



ELONGATED UVULA. 97 

wound to heal as far as possible before it is subjected to the 
irritant action that may be in the food taken. 

Nothing whatever should be applied to the cut unless it is 
rendered absolutely necessary by hemorrhage, as any applica- 
tion will only irritate the surface and delay the healing of the 
wound. The whole of the uvula should never be removed, but 
only the redundant portion ; and there should be left behind a 
fair-sized organ. In the act of swallowing the soft palate is 
drawn up against the pharj^igeal wall, and the uvula fitting 
in the angle formed by the two sides, completes the closure of 
the opening between the pharynx and nose, thus preventing 
the escape of food into the nasal cavity during the act ; the 
complete removal of the uvula, therefore, may impair this 
function. 

7 



CHAPTER VI. 

CKOUPOUS OE EXUDATIVE AFFECTIONS OF THE PHAEYNX. 
Acute Folliculak Pharyngitis. 

This is an acute inflammation in the mucous membrane of 
the pharynx, in which the force of the disease expends itself 
mainly upon the glandular structures and manifests itself by 
a fibrinous exudation into the follicles or glands. As a rule, 
in this affection, scattered groups only here and there are in- 
volved. The causes of the disease, as far as we know, are en- 
tirely comprehended in the one single cause of taking cold. 

Course and sym2)toms. — As in all diseases of the mucous 
membranes characterized by a fibrinous exudation, the onset 
of the attack is marked by a chill or decided chilly sensations, 
followed by fever more or less active in character, the tem- 
perature often reaching as high as 102° or 103°. This is soon 
followed by pain, referable to some portion of the throat, of a 
smarting, burning character, and sense of uneasiness, with the 
symptom always prominent of extreme pain in swallowing. 
This pain is due to the pressure caused by that act upon the 
inflamed and distended follicles. There is often a parched, 
dry feeling in the throat and very rarely an}^ excess of mucus 
secretion. The glands of the neck are occasionally affected, 
showing themselves in little enlarged granules or knots directly 
opposite the diseased portion. 

Examination. — On direct inspection of the fauces the 
mucous membrane proper may be seen to be somewhat red- 
dened and congested, or it may show such slight evidences 
of disease that it may be oftentimes extremely difficult to 
locate nicely or with exactness the source of the trouble. The 
glands or the follicles of the pharynx group themselves along 
the posterior pillars of the fauceSj forming a chain which ex- 



ACUTE FOLLICULAE PHAEYNaiTIS. 99 

tends down low into the pyriform sinuses ; we also find a 
group of glands extending down from the upper pharynx 
below the border of the soft palate. As a rule it is one of 
these groups that is affected. The attack is generally con- 
fined to a single group, and it is only by the closest inspection, 
by direct vision, or by the use of the mirror, that the diseased 
part can be detected. When found, however, there will be 
seen a little irregular mass, with a somewhat nodulated out- 
line projecting above the surface of tlie mucous membrane ; 
broad, red in color, and showing at the apex of each nodule a 
bluish-white spot which is the fibrinous exudation into the 
follicle showing through the thin layer of membrane which cov- 
ers and conceals it. If the diseased part is not easily recognized 
by the mirror, the probe serves oftentimes to localize the 
trouble ; for in passing it down to the SjDot its exquisite ten- 
derness is revealed. 

Treatment. — This is something more than a purely local 
disease ; there is probably a blood condition which so far 
dominates the inflammatory process as to change it from a 
simple catarrhal inflammation to one characterized by an 
exudation of lymph ; this is shown by the prominence of the 
constitutional symptoms ; the chill, with the subsequent fever, 
being something more than would be expected, as merely a 
symptom of so small an extent of local inflammation. Hence 
it is of importance that the general condition should be cor- 
rected by the administration of internal remedies. The remedy 
which seems to meet the condition better than any other is 
quinine, given, for an adult, in doses of from five to ten grains 
repeated twice a day. In addition to this there should be 
given tincture of iron as in the following prescription : 

I^ . Tinct. ferri 3 iij. 

Glycerinse ad. 3 ij. 

M. Dose, one teaspoonful every two hours. 

■Local treatment. — I have fallen into sometlnng of a routine 
practice of applying to all acute inflammations of the follicles, 
locally, a forty-grain solution of nitrate of silver ; confining 
the application as nearly as possible to the diseased part, 
using either the sponge, or probe wrapped with cotton. This 
application is invariably followed by relief to the subjective 



100 DISEASES OF THE FAUCES. 

symptoms, wliicli are oftentimes extremely painful and dis- 
tressing. This application it may be necessarj^ to repeat the 
following day, but as a rule the single application will prove 
sufficient, in connection with the iron and glycerine, which 
seems to exert an almost specific influence in controlling and 
relieving an attack of acute follicular inflammation. This is 
due probably, in part, to the local effect of the iron coming in 
contact with the diseased surface in the act of swallowing, 
but more I think to the effect of its internal administration in 
controlling the blood condition which gives rise to the fibrinous 
character of the exudation. 



C^RO^^IC FOLLICULAK PlIARYI^GITIS. 

This is one of those affections which, owing to its essentially 
chronic character and its intractability, has been regarded as 
almost incurable ; this is due to many causes. As a rule it com- 
mences in a simple catarrhal sore throat, which being allowed 
to take its own course subsides, leaving behind it so slight a 
morbid condition of the membrane as to be unnoticeable. Sub- 
sequent attacks recur with more and more f requeue}^, and sub- 
siding less thoroughly, there finally results a condition of chron- 
ic pliar3nigitis w^hich becomes a permanent source of discom- 
fort. The follicles of the membrane very soon yield to the 
consequent irritation of the catarrhal condition and become 
centres of localized inflammatory processes of a chronic charac- 
ter. We have then occurring in the scattered glands and folli- 
cles the same changes which occur in the tonsils when in a 
state of chronic inflammation or hypertroj^hy ; only in the one 
case there is a large number of glands aggregated to such an 
extent as to constitute a separate organ, while in the other the 
glands are scattered and diffused over a broad surface. This 
chronic inffammation results in the development of small masses 
of glandular tissue in a state of hypertrophy; this hypertro- 
phy consisting of connective tissue, enlarged blood-vessels, and 
^ithelial elements, together with retained secretions which have 
undergone degeneration, the whole constituting little nodules 
standing out prominently on the surface of the membrane, or 
little aggregations of follicles which act as local irritants, and 
give rise to certain subjective symptoms to be described. This 
process of chronic inflammation setting in almost impercepti- 



CHROITIC FOLLICULAR PHARYNGITIS. 101 

bly, as has been stated, progressing from bad to worse by its 
own impetus, is also subjected to certain aggravating surround- 
ings and influences ; occurrences and incidents which the suf- 
ferer would have met with impunity before, now become the 
cause of marked exace'rbations in his troubles ; he becomes es- 
pecially sensitive to changes of temperature ; and the prolonged 
use of the voice, breathing of an impure atmosphere, and cir- 
pum stances of this nature become the causes of renewed attacks 
of acute trouble, or of an aggravation of the chronic symptoms. 
In the early stages of the disease the patient is simply con- 
scious of a certain amount of discomfort in the throat ; per- 
haps a mere dryness of the fauces, with difficulty of swallow- 
ing, due to loss of pliability of the membrane ; or a sense of 
a foreign body in the throat followed soon, perhaps, by a slight 
excess of secretion, with a tendency to expectorate, and some 
little disposition to cough. As the disease progresses the voice 
becomes impaired and weakened ; this is due to a chronic la- 
ryngeal catarrh, which almost invariabl}^ accompanies the later 
stages of the disease ; there is hoarseness, with more or less 
cough, with impairment of voice register. The disease has been 
called clergymen's sore throat, though it is by no means certain 
that clergymen are more liable to it than others ; but of course 
with those to whom the use of the voice is so important, the 
impairment of this organ becomes a somewhat serious matter ; 
and again, the constant use of the voice to which clergymen 
necessarily^ are compelled, serves to aggravate the symptoms. 
In addition to the hawking, expectoration, and cough resulting 
from the excess of secretion from the lower pharynx, there is, 
as a rule, more or less abnormal discharge from the glands at 
the vault of the pharynx, due to the fact that these glands are 
liable to become involved, by an extension to them, of the in- 
flammatory i^rocess which has fixed itself upon the parts below. 
This is not true of every particular case of follicular pharyngi- 
tis, but it is true, probably, of a very large jDroportion ; so that 
in addition to the above-mentioned synii3toms, we have a thick, 
viscid mucus poured out from this source, and flowing down 
between the palate and pharynx, lodges there with considera- 
ble tenacity, and is only removed by a disagreeable nasal scre- 
atus and drawn down into the pharynx below, where it is 
hawked out or swallowed. The pain in the pharynx is usually 
described by patients as a rasping, raw, scraping feeling ; this 



102 DISEASES OF THE FAUCES. 

is due partially to the pressure on the nerves by the enlarged 
follicles, and partially to irritation resulting from tlie labored 
effort and the constant hawking by which the throat is cleared 
of the accumulated mucus. In addition to this there is more 
or less neuralgic pain referable to the throat and neck. This is 
probabl}' due to the involvement of the terminal lilaments of the 
nerves. The lymphatic glands of the neck are often involved, 
being noticeably somewhat enlarged and swollen. The closed 
follicles in the deep layers of the mucous membrane are also 
involved, probably, in this disease. These follicles anatomically 
and physiologically are connected with the general lymphatic 
system. What connection really exists it is not known, but 



n"nr~^ 





f 



Fig. 7-4.— Follicuhir pharyn- Fig. T5.— Follicular pTiarjmgltis in an 

gitis. (Cohen.) aggravated form. (Cohen.) 

that there is a direct connection through the l3^mphatic chan- 
nels with the cervical ganglia is probable. This connection is 
demonstrated as a clinical fact repeatedly, and for the present 
we may simply explain the fact that the cervical glands are en- 
larged in chronic follicular pharyngitis by the analogous and 
probable direct anatomical connection between them and the 
closed follicles of the pharyngeal membrane. 

Inspection. — On examination of the parts, the prominent 
and first thing noticeable is that of a number of rounded pro- 
jections on the surface of membrane of the lower pharynx, from 
the size of millet-seeds to that of a small shot. (Figs, 74 and 75.) 
These are more prominent, and more thickly distributed along 
the pillars of the fauces and opposite the lower border of the 



CHKONIC FOLLICULAR PHARYNGITIS. 103 

soft palate. They are of a dark red color, with a tendency 
to a purplish line ; and lie irpon a mucous membrane which is 
itself of a much darker shade than the normal. 

Occasionally there may be seen, at the summit of these 
prominences, the opening into the crypts of the hypertrophied 
follicles of which they are composed ; and not unfrequently 
protruding from them, masses of cheesy matter, the result of 
retained and decomposed mucus ; though, as a rule, the folli- 
cles contain no cavity, this being destroyed by the encroach- 
ments of the newly deposited connective tissue, which has de- 
stroyed their glandular character. These masses are not infre- 
quently voided in the shape of small, rounded, hardened lumps, 
which upon being broken give forth a most intolerable stench. 

Treatment. — The membrane is covered with a thick, 
shreddy, tenacious mucus, which is closely adherent, and re- 
moved with some difficulty, hence the first measure should be 
the thoroughly cleansing of the membrane by the removal of 
this accumulation. For this purpose one of the cleansing solu- 
tions given in the appendix should be used, preference being- 
given to the first. The best method of applying this is by 
means of the compressed air-apparatus with Sass's tubes, the 
atomized fluid being showered upon the part with a pressure 
of from fifteen to eighteen pounds. 

The force with which the jet is thrown aids the solvent ac- 
tion of the fluid, and serves to thoroughly accomplish the de- 
sired purpose. Richardson's hand-ball spray-apparatus, Fig. 
61, or the little atomizer. Fig. 63, answer a good purpose. 
The same end may be obtained by the use of the post-nasal 
syringe, Fig. 64, the beak being turned downward over the root 
of the tongue. Occasionally it will be necessary to resort to 
the sponge, or a pellet of cotton wrapped on a probe, to detach 
the closely adherent shreds of mucus. It is only after this thor- 
ough cleansing that a proper appreciation of the condition of 
the membrane will be attained, yet it should alwaj^s be borne 
in mind that the result of any application to the mucous mem- 
brane is a temporary, but marked congestion of the parts, 
giving rise to increased redness and some slight swelling. 
After the parts are thoroughly cleansed measures for the cor- 
rection of the morbid condition should be resorted to. In the 
early stages of the affection, before it becomes an essentially 
chronic one, or the follicles markedly enlarged, simple local 



104 DISEASES OF THE FAUCES. 

applications are sufficient ; of these, in order of preference, may 
be used argenti nitras, gr. v. — 3 j., zinci clilorid., gr. v. — x. to 3 j. 
bichloride of mercury, gr. j. — 3 j. In these applications advan- 
tage is taken not only of their astringent action, but also of 
their resolvent power. They may be applied by means of the 
spray or brush, the tongue being well depressed, and the whole 
pharyngeal wall exposed. If the affection has existed for some 
time, local applications are of but limited benefit, and the only 
method of relief will be in the complete destruction of the en- 
larged follicles. For this purpose I know of nothing better than 
the actual cautery. It is almost painless at the time of the ap- 
plication, gives rise to no subsequent annoyance, and is quite 
efficient. A small wire heated to a red heat is applied directly 
to the enlarged follicle, and is pressed into its substance until it 
has burned its way to its base. As the result of a single appli- 
cation generally, the follicle is com2:»letely destroyed ; a slough 




Fig. 76. — Actual cautery wires for the destruction of enlarged follicles in 
the pharyn.x. 

forms, which separates in a few da3^s, leaving a small cavity 
which heals kindly. For this purpose I have had consti'ucted a 
set of small wires. Fig. 76, with their points fashioned to adapt 
them for the destruction of follicular enlargements of varying 
shapes and sizes. Occasionally I have resorted to the use of 
the knife, making a free incision directly through the mass of 
the enlarged follicle, and cauterizing the cut surface with a solid 
stick of nitrate of silver. This procedure is an efficient one, 
but somewhat painful; the use of the cautery is preferable. 
The use of chromic acid, Vienna paste, caustic potash, and the 
galvano-cautery has been advised ; they possess no advantages 
over the methods suggested, and many disadvantages. De- 
struction of the afferent blood-vessels has been recommended, 
on the ground that this procedure will lead to the atrophy of 
the enlarged follicle ; the destruction of the follicle itself is 
quite as simple a procedure ; and, moreover, it is not possible 
to localize the blood-vessel which supplies the enlarged gland, 



CHEOlSriC FOLLICULAK PHAETNGITIS. 105 

comparatively few of tliem showing on tlie surface ; and again, 
I am disposed to think that these hxrge blood-vessels are more 
frequently seen in chronic catarrhal pharyngitis than in the 
follicular disease. If, as is usually the case, the larynx be af- 
fected, the voice should be given as near absolute rest as is 
attainable ; this not only for the direct injurious effect of using 
the voice on the disease of the laryngeal membrane, but for its 
indirect injury to the pharynx. This, of course, in a clergyman, 
or one whose occupation involves an amount of public speak- 
ing, can only be obtained by the abandonment for a time of 
the occupation. This should nevertheless be insisted upon, 
else it will soon be forced upon the sufferer by the exigencies 
of his infirmities, rather than by the advice of his physician. 
Any impairment of the general health must be corrected by 
such measures as are especially indicated, and which need not 
here be enumerated. The cough which oftentimes accompa- 
nies the disease may be of such an annoying and harassing 
character as to demand relief. 

As a rule, the ordinary anodyne cough-mixtures should be 
avoided, as indirectly exercising an injurious effect upon the 
original disease, in that their tendency is to impair the diges- 
tive function. There are two remedies which exercise a direct 
and almost specific influence on the mucous membrane of the 
throat ; these are cubebs and ammonia. Just how this influ- 
ence is exercised is not known, but probably in each case the 
action is somewhat similar, in that, being taken into the general 
system and absorbed by the blood, the volatile element of the 
drug is eliminated to a degree through the mucous membrane 
of the upper air-passages. In the case of ammonia, in what- 
ever form the drug is taken, it is in part converted into the 
carbonate, and in this form is eliminated. Cubebs on the other 
hand contains, the volatile element, cubebic acid, which, when 
taken into the system, is also eliminated through the upper air- 
passages. The best method of administration of the ammonia 
for the relief of cough and the symptoms of follicular sore 
throat, is in the form of the muriate and in lozenges. In this 
manner there is obtained botli a local and general effect of the 
drug. Its local effect is stimulating ; whereby, coming in con- 
tact witli- the membrane it excites it to a somewhat freer secre- 
tion, relieving it of its coat of thick tenacious mucus, relieving 
the epithelial coating of the membrane, choked as it is usu- 



106 DISEASES OF THE FAUCES. 

ally, relieving the engorged blood-vessels somewhat, and thus, 
by a process of local depletion, as it were, relieving the promi- 
nent subjective symptoms for a time. This action is further in- 
creased by the escape through the membrane of a portion of 
the ammonia which has been taken into the system ; its action 
in this manner being somewhat similar to that which results 
from its direct contact with the diseased surface in deglutition ; 
it stimulates the membrane to a somewhat freer secretion, caus- 
ing it to sux)ply a larger amount of moisture to the mucus, 
thus loosening the cough. Cubebs should be administered by 
preference in the form of a powder prepared freshly and from 
the fresh new berry ; the object of this being, that the drug 
should contain as largely as possible of the cubebic acid which 
is its efficient constituent. Its action, like that of ammonia, is 
due partially to its local effect, and partially to the action of 
the passage of the cubebic acid through the membrane in the 
upper air-passages in its elimination. It exercises a certain 
stimulating effect on the membrane, followed almost immedi- 
ately by a sedative action, whereby relief is given to the sense 
of soreness or rawness of the throat, the deglutition, and dis- 
position to cough. These drugs may be administered sepa- 
ratel}^ or they may be combined with benefit, as in the fol- 
lowing : , 

1^ . Pulv. cubebae 3 iij. 

Syr. aurant. cort ad. § ij. 

M. Dose, one teaspoonful. 

}J . Mur. ammoni8B 3 ijss. 

Syr. tolu, 

Aqufe ^i''^ 1 J- 

M. Dose, one teaspoonful. 

]J. Fl. ext. cubebfe, 

Mur. ammonise ^a 3 ij- 

Elixir simpl 3 ij- 

M. Dose, one teaspoonful. 

3. Potass, chlorat., 
Pulv. cubeba3, 

Sacch. alb aa I j. 

M. Taken on the tongue, ad lib. 



CEOUPOUS PHAEYNGITIS. 107 

Occasionally relief will be obtained from chewing the dry 
cubeb-berry. In this way the drug is used in a form in which 
it contains its volatile element in the largest amount. 

As regards other indications for treatment, it may be simply 
noted that any impairment of the general health should be 
remedied by proper remedies ; and any tendencies or existing 
diathesis corrected as far as possible. 



MEMBEAisrous SoEE Theoat oe Ceoupous Phaeyistgitis. 

This consists of an acute inflammation of the mucous lining 
of the pharynx, characterized by the exudation of a fibrinous 
material that coagulates upon the surface of the membrane, 
forming a grajdsh, pearl-colored pellicle which is oftentimes 
mistaken for diphtheria. The favorite site of this exudation is 
on the surface of the tonsil, though it may extend somewhat 
to the soft palate and pillars of the fauces. As a rule it is 
confined to one side, though occasionally it appears on both 
sides ; if this be the case, however, the dejDosit is usually 
greater on one than the other. It is not contagious or infec- 
tious, it runs a somewhat limited course and its tendency is 
always to get well. As has been said before, there is probably 
some antecedent condition of the blood, which so far domi- 
nates and controls the inflammatory process as to lead to a 
deposit or exudation instead of a simple catarrhal affection 
which would ordinarily result from catching cold, this being, 
as far as we know, the usual and prominent cause of the 
trouble. What this antecedent condition is it is not easy to 
say, but it is probable that it is analogous or similar to what 
we know as hyperinosis, viz., that condition of the blood in 
which there is an excess of fibrin. As a result of this condi- 
tion, we find that the disease is ushered in by a chill, followed 
by high fever, which is more marked than we should ordinarily 
expect to find in connection with or symptomatic of an inflam- 
matory affection of so limited extent. The febrile motion we 
must therefore attribute to the blood condition and regard the 
affection as something in the nature of an essential fever with 
a local manifestation. This chill may be a well-marked chill 
or simple chilly sensations followed by more or less prominent 
general symptoms, such as pains in the bones, headache, and 



108 DISEASES OF THE FAUCES. 

general malaise. The fever sets in very soon, and is marked 
by a temperature ranging from 101° to 103°. 

In connection with the fever, the symptoms referable to the 
throat become prominent ; there is a parched, hot feeling, with 
pain of a somewhat lancinating character, referable to the fau- 
ces, together with soreness and stiffness about the jaws. Deglu- 
tition becomes extremely painful, due probably to the fact 
that the glands and follicles are involved in the inflammation. 
The 1}' mpliatic glands of the neck are somewhat swollen, though 
to a very slight extent, as a rule. Occurring, as this disease 
does, more frequently in children than in adults, the symptoms 
are oftentimes of an extremely alarming character. This alarm 
is very much increased by the discovery on inspection, of the 
patch in the throat, which is so inseparably connected in the 
minjis of the laity with diphtheria ; it is greatly enhanced also 
by the aggravated form, which the febrile movement gener- 
ally assumes. It therefore becomes of no little importance to 
recognize membranous sore throat as a disease separate and 
distinct from diphtheria, and also, of course, to make an un- 
mistaken diagnosis. This can be done with almost absolute 
certain!}^ in most cases, the diseases presenting certain charac- 
teristics which render them unmistakable. 

On examination of the fauces in membranous sore throat, 
we find the whole mucous membrane of the pharynx involved 
in a state of active and acute catarrhal inflammation ; the mem- 
brane is reddened, and of a bright, almost scarlet color, this dis- 
-coloration and injection extending somewhat to the pillars of 
the fauces, the palate, and uvula. The tonsils are somewhat 
thickened and raised from their bed, and present on the surface 
of one or both a whitish-gray membrane with a bluish or pearly 
tint. The mucous membrane surrounding the patch presents 
no marked areola of redness, but it is of the same color as that 
of the membrane of the whole fauces as far as the catarrhal in- 
flammation extends. The edges of the membrane are well de- 
fined and rounded. The patch presents all the appearance of 
a live membrane, in distinction from the membrane in diphthe- 
ria, which is a dead membrane or necrosed tissue. The patch 
is somewhat limited in extent and confined to the surface of the 
tonsil ; very rarely it may extend on to the pillars of the fauces 
or soft palate, and occasionally to the phar3aigeal wall. This 



CROUPOUS PHARYNGITIS. 109 

tendency to extension, however, is extremely limited. The 
membrane in the earlier stages is soft and friable, and easily 
wiped off, breaking up into soft bran-like particles. In the 
later stages, when the membrane is fully organized, it is still 
easily removed, and is torn off in a thin pellicle, showing that it 
is deposited on the surface of the membrane, which is charac- 
teristic of croupous exudation, in contradistinction to the diph- 
theritic exudation, which involves the whole thickness of the 
mucous membrane. 

The, distinctive differences between the exudation of mem- 
branous sore throat and that of diphtheria will be more clear- 
ly apprecia ted by placing them in a tabular form. 

Membranous Sore Throat. Diphtheria. 

A grayish-white, pearly membrane. A dead white, opaque membrane, with 

a blackish tinge resembling boiled mac- 
caroni. 
All the appearances of a living mem- All the appearances of a necrosed 

brane. membrane. 

No areola. More or less marked areola. 

Rounded, well defined edges. Edges ragged and somewhat everted. 

Feebly attached to the parts beneath. Firmly attached to the parts-beneath . 

Easily removed without bleeding. Only detached by violence, resulting 

in hemorrhage. 

Treatment. — From what has been said, it will be seen that 
the disease under consideration is largely a systemic disease 
with a local manifestation ; hence a prominent indication for 
treatment lies in the correction of the blood condition. For 
this purpose quinine should be given, and freely. From ten to 
fifteen grains should be given to an adult, and smaller doses in 
proportion to children. This should be repeated, if necessary, at 
the end of twelve hours, according to the amount of febrile move- 
ment still remaining. If there is much pain, headache, or sore- 
ness about the jaws, with difficulty in swallowing, a small 
amount of Dover's powder may be added to the quinine. 
Aconite also serves to promote resolution, and to exercise a 
special influence on the fauces ; it should be given in doses of 
from half a drop to one drop every hour. The local treatment 
involves the complete removal or destruction of the membrane. 
In the earlier stages this should be wiped off or detached as thor- 
oughly as possible, and the site painted with a solution of ni- 



110 DISEASES OF THE FAUCES. 

trate of silver, 3 J. — 3 j. This, as a rule, not only prevents its 
reproduction but relieves the pain. If there is much acute 
pharyngitis accompanying the attack it may be treated by sim- 
ple astringent sprays or gargles. Iced or acidulated drinks 
may be given freely, or pellets of ice may be allowed to melt in 
the mouth or rest against the inflamed fauces with comfort and 
relief. 



CHAPTER VII. 

ACUTE APFECTIONS OF THE TONSILS. 

General Considerations. — In describing the general con- 
struction of mucous membranes, it was stated that they are 
largely endowed with glands and follicles which show a ten- 
dency to group themselves in certain localities, as in the vault of 
the pharynx and between the pillars of the fauces. The group 
between the pillars of the fauces is so extensive as to constitute 
it an independent organ, under the name of the tonsil. These 
glands are two almond-shaped bodies, made up of a number of 
compound follicular glands, whose orifices, uniting with each 
other, open on the free surface of the membrane by about fif- 
teen or twenty openings. These follicles are simply inf oldings 
of the mucous membrane, by which a llask-like cavity is formed, 
lined with a thin layer of glandular epithelium. The outer 
wall of the glands is formed by a layer of connective tissue, to- 
gether with a delicate fibrillary vascular layer. In this layer 
we find imbedded a number of closed follicles, containing a 
large number of cells and free nuclei lying in a clear fluid. 
The tonsils are in relation externally to the superior constric- 
tor muscles of the pharynx, internally with the carotid and 
ascending pharyngeal arteries, and lie opposite the angle of 
the jaw. The arterial supply, which is very abundant, is de- 
rived from the dorsalis linguae branch of the lingual, the de- 
scending palatine and tonsillar branches of the facial, the 
ascending pharyngeal branch of the external carotid, and the 
descending palatine branch of the external maxillarj^ arteries. 
The veins empty into the tonsillar plexus, on the side of the 
tonsil. The nerve supply is from the fifth pair and the glosso- 
pharyngeal nerve. 

The function of the tonsil is probably twofold. Its secre- 
tion is derived from the follicular glands of which it is largely 
composed, and also from the closed follicles in the deep layer, 



112 DISEASES OF THE FAUCES. 

wliicli also pour out or supply, either by the rupture and escape 
of their contents or by transudation, a clear viscid fluid con- 
taining cells and nuclei. This secretion is poured out upon the 
bolus of the food as it passes the isthmus of the fauces, and 
facilitates its progress into the oesophagus. The existence of 
the closed follicles in the deep laj^ers of the connective tissue 
entitle the tonsil to be regarded as one of the ductless or blood- 
glands, which are very nearly allied to the lymphatic glands. 
These follicles play the same part in the economy as in other 
analogous glands, viz., by producing some change in the con- 
stituents of the blood. 

The affections whicl> we meet with in the tonsils are acute 
tonsillitis or quinsy sore throaty subacute tonsillitis, acute fol- 
licular tonsillitis, and chronic tonsillitis or hypertropTiy of the 
tonsils. These diseases only will be considered for the present, 
although other affections are met with occasionally, such as tu- 
mors, chalky concretions, epithelioma, carcinoma, and gangrene. 
These, however, are diseases frequently met with in all parts of 
the body, and when making their appearance in the tonsil 
present no characteristics which are peculiar, and give rise to 
no symptoms that are unique, but obey the same rules which 
govern them wherever they occur. The affections of the ton- 
sil in diphtheria, small-pox, scarlet fever, and measles being 
merely symptomatic, and not essential diseases, their consider- 
ation properly belongs to treatises on the general diseases which 
give rise to these conditions. 



Acute Tonsillitis, or Phlegmonous Tonsillitis. 

In the confusion of our medical nomenclature we find this 
disease laden with a large number of names, such as phlegmo- 
nous sore throat, cynanche tonsillaris, angina faucium, amyg- 
dalitis, and quinsy, a simple corruption of the Latin term cy- 
nanche. We adopt the term acute tonsillitis, as best defining the 
disease under consideration. It is an acute phlegmonous in- 
flammation attacking the fauces, in which the tonsil is the 
starting-point of the inflammatory process, and bears the brunt 
of the disease, but also involving the mucous membrane and 
cellular tissue of the parts adjacent. It is characterized by 
marked swelling and infiltration of the parts, with a decided 



ACUTE TONSILLITIS, OE PHLEGMOlSroUS TONSILLITIS. 113 

tendency to suppuration and the formation of an abscess ; there 
is increased secretion, with more or less constitutional disturb- 
ance. As to the causes of this affection very little more can be 
said than that the prominent exciting cause is exposure to cold, 
and that the most frequent predisposing cause is a previous 
attack. It is generally asserted that persons of a strumous 
habit are peculiarly liable to quinsy sore throat, yet we find 
that it occurs in the healthy and robust with even more fre- 
quency than in those of the strumous habit. Again, it is said 
that persons in ill-health from any cause are liable to attacks, 
yet we frequently meet with those in the enjoyment of perfect 
health who are attacked with this affection under very slight 
provocation. As to age, it is more common in children and 
3^oung persons than in adults. This is probably due to the 
greater frequency with .which we meet with enlarged tonsils in 
children. It is more frequent in men than in women, owing to 
the greater exposure to cold to which men are subject. The 
existence of a chronic enlargement of the tonsils is unques- 
tionably a prominent predisposing cause. 

Bymptoms. — It is generally ushered in by a chill more or 
less well marked, followed by general febrile movement. At 
times its onset is marked by merely chilly sensations. The 
febrile movement is attended with the ordinary phenomena 
of symptomatic fever, viz., headache, pains in the limbs, full 
pulse, and hot skin, the temperature oftentimes reaching 102° 
to 103°. Following very soon upon these symptoms, the pa- 
tient commences to experience some dryness, with a sense of 
uneasiness in the throat, the secretion from the mucous mem- 
brane at the onset of the affection being diminished. This is 
soon followed by acute pain, shooting toward the ears with 
each attempt at swallowing : these symptoms becoming rapidly 
aggravated, each attempt at deglutition is attended with such 
increasing pain, that the features are convulsively contracted 
by the act, and the suff!erer soon becomes unwilling to make 
the attempt. The movements of the jaw become so painful and 
restricted that the opening of the mouth is rendered almost 
impossible ; the breath becomes offensive, emitting a sour, fetid 
odor, and the glands of the neck enlarged and hardened. 
The neck itself becomes swollen and stiff, and there is more 
or less difficulty of breathing, owing to the mechanical inter- 
ference with the free ingress of air. As the result of the febrile 
8 



114 DISEASES OF THE FAUCES. 

movement, tlie difficulty of breathing, and the increasing pain 
in the fauces and neck, sleep becomes difficult or impossible. 
Deglutition is not only painful, but the food is regurgitated into 
the mouth or nasal passages ; this is due to the fact that the 
muscles of the fauces are paraly^d, and fail to perform their 
proper function of closing up the naso-pharyngeal and oro-pha- 
ryngeal opening, in the act of deglutition. Tliis paralysis is 
explained as follows : In the severe forms of inflammatory dis- 
ease, such as we are dealing with, there is a certain amount of 
serous exudation beneath the membrane, which extends to and 
involves the muscular structures, thus infiltrating them in such 
a manner that their contraction is seriously interfered with ; 
in fact, they are paralyzed, and fail to perform their special 
duty in deglutition. If the inflammation has extended into the 
pharynx, the constrictor muscles of the pharynx are liable to 
become paralyzed in the same manner, and the difficulty in 
swallowing, of course, becomes greatly aggravated. If now, in 
this condition, the attempt is made to take food and the bolus 
has passed into the pharynx, the patient can pass it neither 
forward nor backward, and his condition becomes an extreme- 
ly alarming one ; for if in this dilemma he attempts to breathe, 
there is danger of the mass passing into the larynx, and indeed 
this is not an unfrequent occurrence. The secretion of saliva 
is also stimulated and greatly increased, only to add to the 
misery and discomfort of the sufferer, for being unable to swal- 
low or expectorate, he is compelled to sit with his head bent 
forward to allow it to trickle from his mouth. At this stage 
of the disease he presents a typical picture of suffering and de- 
spair ; he refuses alike food and medicine, on account of the 
exquisite pain caused by the mere attempt to swallow, made 
as it is with his face resting on his hands and his elbows on 
his knees, the head bent forward and the mouth open to allow 
the mucus and saliva to escape without involving the painful 
effort of hacking or clearing the throat. The voice is early af- 
fected, and changes in character, becoming muffled and thick, 
and loses entirely its nasal tone. Deafness is oftentimes a 
symptom, the enlarged tonsils pressing upon and closing the 
orifices of the Eustachian tubes. 

On examination^ if the mouth can be opened sufficiently to 
allow of it, there will be seen bulging forward a large rounded 
tumefa€tion, displacing not only the tonsil but the soft palate, 



ACUTE TONSILLITIS, OE PHLEGMOISTOUS TOiS"SILLITIS. 115 

uvnla, and palatine arches. The nmcous membrane is swollen, 
dark red, and covered with a clouded secretion. The uvula is 
swollen and often elongated, resting upon the base of the 
tongue. If both tonsils are involved they are often seen to meet 
in the median line. The tumefaction is somewhat irregular in 
outline, and there may be often seen at the orifices of the folli- 
cles of the tonsil, a yellowish, creamy secretion, which may be 
mistaken for a diphtheritic patch ; it can, however, be easily 
removed by a probe, and will be found to be soft and friable, 
and possessing no fibrinous character. 

The termination of acute tonsillitis is either by resolution 
or suppuration. It runs its course generally in from six to 
ten days, the height of the fever being reached generally by 
the fifth day. If both tonsils are involved, suppuration 
generally takes place in but one. The presence of pus may 
be detected either by the soft feel of the tumor, by the fluc- 
tuation, or by indications of its pointing at some place on 
its surface. The abscess may be discharged during the act of 
deglutition or vomiting ; it may break at night and its con- 
tents pass into the stomach, or the pus may be discharged into 
the pharynx, giving rise to serious troubles ; death by suffoca- 
tion having occurred by the escape of the contents of the ab- 
scess into the larynx during sleep. The relief following the 
discharge of the pus is very marked and almost instantaneous. 

Treatment. — In this as in other acute inflammatory disor- 
ders, attended with a high symptomatic fever, it is well, at the 
onset of the attack, to administer a mild cathartic ; and there 
is nothing better than a glass of one of the aerated bitter 
waters, as Pullna, Friedrichshall, Hunyadi Janos, etc. Fail- 
ing these, a glass of the citrate of magnesia solution, or two or 
three drachms of Sal Kochelle may be given. 

In seeing these cases of quinsy at the commencement of the 
disease, the question of bloodletting has frequently suggested 
itself; and although I have never had the moral courage, in 
the face of the popular prejudice existing in our day against 
this procedure, to put it in practice, it seems to me that it 
would not only be a justifiable measure, but would be attended 
with most excellent results in curtailing the severity of the at- 
tack, and possibly in averting it. The disease is essentially a 
sthenic one, as evidenced by the full bounding pulse, distended 
blood-vessels, and general plethora which characterizes it ; and 



116 DISEASES OF THE FAUCES. 

moreover, as it generally attacks those in robust health, the 
question of venesection is worthy of consideration, unless es- 
pecially contraindicated by the condition of the patient or 
the asthenic type which the disease occasionally assumes. 

If there is any irritating or undigested food in the stomach, 
it should be gotten rid of by the administration of an emetic, 
preference being given to such as are not depressing in their 
action, as mustard, common salt, or simple warm water. The 
advantage of this measure is not only in the relief to the over- 
loaded stomach, but also a certain amount of relief afforded to 
the swollen tonsils and palate in the pressure exerted on their 
engorged blood-vessels, in the act of vomiting ; and in the re- 
moval also of the mucus which adheres to them. 

If the patient is seen on the first day of the attack, an at- 
tempt should be made to avert it. This I believe can be accom- 
plished in many cases by the following i)lan. A full dose of 
quinine as follows should be given : 

IJ . Pulv. opii gr. j. 

Pulv. capsici gi'- ij- 

Quin. sulph gi"- x. 

M. 

This may be given in a rice wafer, which is usually easily 
swallowed. If there is any difficulty, of course the method of 
administration may be changed and the dose given in solution as 

IJ. Tinct. opii mxij. 

Tinct. capsici mxv. 

Quin. sulph gr- x. 

Acidi sulph dil. q. s. 

Aquse ' ad. 3 j. 

M. 

This should be followed immediately by the administration of 
aconite in full doses, frequently repeated. Owing to the uncer- 
tain strength of this drug, it is often difficult to nicely regulate 
the dose in such a manner as to obtain just the result desired. 
For this reason Fleming's Tincture should be preferred, as afford- 
ing a preparation Avhose strength is more nearly unvarying than 
any other. Of this preparation there should be given from 



ACUTE TONSILLITIS, OR PHLEGMONOUS TONSILLITIS. 117 

one to three droiDS every hour, until its physiological effect is 
manifested in dryness of the fauces, dizziness, disturbance of 
the stomach, lowering of the pulse, etc. As a rule, this result 
will be obtained by the exhibition of two or three doses ; no 
more than three should be given, however, in any case. The ob- 
ject of the aconite treatment is both to obtain its constitutional 
effect in controlling the general febrile symptoms, and also its 
local action on the fauces. If given early enough in the course 
of the disease this plan will often serve to break up and abort 
the attack. If this is not accomplished on the first day by the 
above-detailed procedure, it may be repeated on the second day ; 
later than this, however, little can be expected from it, and other 
measures must be resorted to. These consist in internal and 
external applications. Of the external applications, none are so 
grateful to the patient as moist heat ; this should be applied in 
the form of soft flannels, wrung out in water as hot as can be 
borne, and laid on the neck, the heat and moisture being re- 
tained by a piece of oil silk laid over the compresses. They 
should be changed often, and the procedure faithfully per- 
sisted in, until resolution or suppuration occurs. Much relief 
will be afforded by the application to the fauces of a mild as- 
tringent, such as potass, chloratis, 3 ss. — 3]., cupri sulphat., 
gr. X. — 3]"., zinci sulphat., gr. x. — fj., tannin, 3j. — 3]., etc. 
These should be ajDplied by preference in the form of the 
spray, the little atomizer. Fig. 63, answering an excellent 
purpose. Better still, however, is the steam atomizer, which 
gives the valuable aid of the hot steam in connection with the 
astringent. The effect of this is to cleanse the fauces of the 
accumulated mucus, which the patient as a rule is not able to 
ex^oectorate, and also to control to an extent the acute inflam- 
mation of the mucous membrane which covers the phlegmonous 
tumor. 

Pellets of ice are often grateful to the patient, being held 
in the mouth, or allowed to lie against the inflamed part, the 
head being thrown back. The persistent use of the hot appli- 
cation externally, with the hot steam internally, will serve a 
better purpose, however ; and the plan is a more consistent 
one than that of cold applications internalh% in connection 
with hot compresses externally. 

As regards tlie administration of drugs at this stage of 
the disease, I am disposed to place little reliance on them ; 



118 DISEASES OF THE FAUCES. 

althoiigli good aiitliority will be found in the text-books for 
the use of no small part of the pharmacopoeia, including 
guaiac, quinine, aconite, tinct. of iron, opium, belladonna, 
tartar emetic, chlorate of potassa, and numberless others. 
That guaiac exercises a controlling influence in quinsy, occa- 
sionall}^, is undoubtedly true ; and this would seem to afford 
evidence of the truth of the view, which regards quinsy as a 
manifestation, often, of the rheumatic diathesis. On the other 
hand this whole subject of a special diathesis as governing the 
development of throat diseases, rests on such uncertain clinical 
observation that it seems to me that it only serves to confuse, 
and that we attain a clearer understanding of them by ignor- 
ing it and regarding these affections as purely idiopathic and 
local. As regards the use of other drugs, they are so uncer- 
tain in flieir action that we may as well confess that we possess 
no speciiic in acute tonsillitis, and content ourselves with sim- 
ply treating symptoms, administering mild anodjmes to re- 
lieve pain, and bending our efforts toward the promotion of 
the inevitable suppuration, if the abortive plan has failed ; 
and this can best be accomplished by the application of heat, 
externally and internally, as suggested above. The question 
of using the knife will present itself early in the attack, and 
although it is often condemned unless there is evidence of pus 
formation, my own experience induces me to regard it as a 
valuable method of relief, and whether there is pus detected 
or not, I am accustomed to scarify freely. For this purpose 
a sharp-pointed, straight bistourj^ should be used, which may 
be thrust directly into the tumor with its cutting edge toward 
the median line, and then made to cut its way to the surface. 
Whether pus is evacuated or not, blood is drawn freely, and 
serves markedly to relieve the engorged blood-vessels and 
thereby to alleviate the distressing features of the disease. I 
have never seen an}^ harm result from free scarification, but 
often much relief. It should be remembered, however, that 
the cutting should be made in the tonsil, and that the pillars 
of the fauces should not be cut through, as in this case per- 
manent injury might be done in impairing the function of 
deglutition. If the tumor points high up in the palate, as it 
often does, the use of the knife should be confined to a simple 
incision or thrust, as, of course, cutting from a point high up 
on the palate, out to its free border, might do jDermanent injury. 



SUBACUTE TONSILLITIS. 119 

In addition to the above measures there can be little else 
done, save the administration of concentrated nutrition, and 
sustaining the strength of the patient hy such means as are 
possible. At best, the management of a case of quinsy is not 
satisfactory, the suffering of the patient is acute, 'the efforts of 
the physician to relieve but partially successful ; still much can 
be done in the direction of cutting short the attack, and much 
in alleviating the more distressing symptoms. 



Subacute Tonsillitis. 

This is an inflammation of the parenchyma of the tonsil, of 
a catarrhal character, in which the inflammatory process con- 
fines itself entirely to that organ. It is of a mild type and 
limited duration, involving no serious consequences, and at- 
tended with none of the extremely painful symptoms which 
characterize quinsy sore throat, nor does it manifest any ten- 
dency to suppuration as does the graver affection. It may 
involve one or both tonsils, and consists in an attack of inflam- 
mation of the organ attended with marked increase of blood 
supply, a considerable swelling or tumefaction of the organ, 
and an increased secretion of mucus from its glandular struc- 
tures. It is ushered in by chilly sensations, followed soon by 
mild symptoms of febrile movement, as evidenced by heat of 
skin, muscular pains, loss of appetite, and a moderate increase 
of temperature. Following the febrile motion there soon oc- 
curs a sense of discomfort about the fauces, with pain at the 
angle of the jaws and soreness extending to the cervical mus- 
cles. The movements of the jaw become somewhat impaired 
and painful. Swallowing is attended with more or less pain, 
from the pressure exerted on the inflamed tonsil by that act. 
The voice becomes affected by the mechanical interference with 
the free egress of the vocal waves, and assumes a thick and 
muffled tone. There is no cough, but a constant disiDOsition to 
liawk and clear tlie throat of the accumulated mucus. 

The affection results from taking cold, though the promi- 
nent predisposing cause is the existence of a moderate degree 
of hypertrophy of the tonsil. These attacks do not occur, how- 
ever, so frequently in cases of extreme hypertrophy of the ton- 
sil, wherein the tonsil projects a large, irregular, rounded tumor 



120 DISEASES OF THE FAUCES. 

from its bed, but occur rather in those cases of enlarged ton- 
sils which consists in a moderate degree of hypertrophy in 
which the organ lies broadly and flatly in its bed, not project- 
ing to any extent beyond the pillars of the fauces, but is sim- 
ply enlarged to that extent that the space between the pillars 
of the fauces is distended laterally, viz., in those cases in which 
the tonsil is recognizable as enlarged, and yet not sufficiently 
so for extirpation b}- the tonsillotome. 

The examination in this affection shows one or both tonsils 
enlarged, protruding from their bed, of a bright, angiy-looking 
red color, in which the morbid process contines itself to the 
tonsil alone, the palate and uvula being, as a rule, in no de- 
gree affected. If both tonsils are involved they may be en- 
larged to the extent of meeting in the median line. They are 
coated with a thick, rojjy, semi-opaque mucus, which adheres 
closely, and is hawked up with some difficult}^ This condition 
should not be confounded with acute tonsillitis or follicular 
tonsillitis. In acute tonsillitis there are all the evidences of a 
phlegmonous inflammation, with a tendency to su23puration. 
The symptoms are more prominent, and the pain of a more dis- 
tressing character. The tumefaction also extends to the palate 
and surrounding soft parts, whereas, in the affection under 
consideration, the morbid process is conflned entirely to the 
tonsil. There is no tendency to suppuration, and none of that 
deep-seated throbbing pain which indicates the formation of 
pus. 

In acute follicular tonsillitis the morbid process is also con- 
fined mainly to the tonsil, but it consists in a fibrinous exuda- 
tion, which is poured out into the crypts of the follicles, and 
shows itself in the pearly white spots on the surface of the 
organ ; these are absent in the affection under consideration. 
As has been said, the affection is purely catarrhal in its nature, 
is not contagious, but shows a decided tendency to recurrence, 
especially during the Spring and Fall months, when all catar- 
rhal affections are aggravated, and are liable to exacerba- 
tions. 

Treatment. — The affection is not a serious one, nor attended 
with any grave sj^nptoms ; hence, oftentimes, it becomes only 
important with reference to its diagnosis ; it may, however, give 
rise to more or less distressing symptoms, and, in all cases, 
should be subjected to treatment on account of its tendency to 



SUBACUTE TONSILLITIS. 121 

recurrence, and from the fact that, each recurrence leaves the 
organ in a less healthy state than that which existed before. 
It is through repeated attacks of this affection that chronic 
enlargement of the tonsil is frequently developed. At the 
outset of the attack a saline laxative should be given, fol- 
lowed in the course of one or two hours by from five to ten 
grains of quinine. If given early enough, the attack may be 
aborted by this procedure, but unless this is attained within 
from twenty-four to thirty-six hours, the disease will run its 
course of from four to six days. The quinine failing to arrest 
it, resort should be had to the use of aconite. The use of this 
drug in the early stages of an acute inflammation in the fauces 
is, undoubtedly, of great benefit, in not only exerting an influ- 
ence on the febrile motion, but as also exerting a- specific and 
localized influence on the fauces. In the affection under consid- 
eration most excellent results can be obtained by its use. 
The method I usually pursue is to give, according to the age 
of the patient, from half a minim to two minims of Fleming's 
tincture every hour, for three or four hours, or until the physi- 
ological effect of the drug has been obtained, in the dryness 
and tingling about the fauces, then ceasing until the next day, 
when it should be repeated, unless decided relief has been ob- 
tained from the prominent subjective symptoms. This plan 
may be pursued on the first and second day, but, as a rule, it 
will prove of little avail any later. 

As will be noticed, the plan of treatment recommended is 
very similar to that of acute tonsillitis. The disease is of 
course nearly related to that of quinsy, and up to a certain 
point is quinsy ; but while the one develops into a phlegmon- 
ous infiammation, the other remains a simple catarrhal process. 
The condition to correct at the onset being then much the same, 
the treatment is similar. The administration of. the aconite 
may be commenced immediately after the laxative has been 
given. 

In addition, much relief will be afforded by the use of a 
gargle of chlorate of potash, alum, borax, tannic acid, etc., as, 
properly used, they may be allowed to come in contact with a 
large portion of the diseased organ. Pellets of ice, either swal- 
lowed or allowed to lie against the inflamed organ, by throwing 
the head back, will prove grateful to the patient, and serve in 
a degree to control the morbid process. Steam inhalations are 



122 DISEASES OF THE FAUCES. 

of no avail, nor sliould the applications externally, of either 
hot or cold water, be encouraged, as their advantage is but very 
limited. As a rule, it may be stated, in regard to this affection, 
that we possess the means of limiting and controlling it in the 
internal administration of remedies which are more cleanly, 
more simple, and more efficient than the uncleanly, and often- 
times even mischievous external applications of hot poultices, 
fat pork, onions, poppy-heads, hops, cold cloths, ice bags, and 
indeed the whole category of domestic remedies of this kind. In 
a large majori ty of cases these applications are not properly made 
and not properly followed up. If cold applications are used they 
are allowed to remain until they become hot, and thus act as fo- 
mentations ; if hot applications are used, they are allowed to re- 
main until they become cold, and their original design is thus 
aborted. It may be added that they are extremely liable to add 
to the discomfort of the patient rather than to his comfort. This 
of course is only intended to appl}^' to the mild affection under 
consideration, for while in the graver and more distressing 
acute disease these hot applications are of the greatest value, 
and on account of the severity of the suffering it entails they 
will be applied faithfully and with care, and with the purpose 
of promoting suppuration ; in the milder disease the same 
care will not be exercised, and moreover their design of hasten- 
ing pus-formation is not an object of treatment. 

In addition to what has been suggested in regard to local 
applications, it may be added that relief will be afforded by the 
use of astringent solutions thrown on the diseased part in the 
form of spray. This is of benefit not only in the local action of 
the solution used, but also in serving to cleanse the tonsil of 
the thick mucus which adheres to it. In this manner there 
may be used sulphate of zinc, gr. x. — Ij., chloride of zinc, 
gr. V. — f j. ; to which may be added a small portion of carbolic 
acid, two minims to the ounce. The little atomizer shown in 
Fig. 63 serves excellently for these applications, and can easily 
be manipulated at the hands of the friends or attendants. 

The question often suggests itself, in connection with this 
affection, of amputating the tonsil during one of the attacks. 
This I believe to be a perfectly justifiable procedure ; the ob- 
ject being not only to cut short the existing attack, but also to 
remove the cause of the recurring attacks. An additional jus- 
tification for the operation during an attack is, that in very 



ACUTE FOLLICULAE TONSILLITIS. 123 

many of these cases tlie tonsil, after tlie subsidence of the at- 
tack, sinks so entirely into its bed behind the pillars of the 
fauces as to render the operation somewhat difficult. Whereas, 
when it is swollen by the inflammatory process, it presents an 
exceedingly favorable form for excision. 



Acute Follicular Tonsillitis. 

This affection is an acute inflammation of the tonsils in 
which there occurs an exudation of fibrinous material which is 
poured out into the cavities of the follicles which compose the 
organs and so far fills up and distends them, that there results 
a far greater amount of pain and tenderness in the parts, due 
probably to pressure on the terminal filaments of the nerves, 
than are met with in simple catarrhal inflammation ; and also, 
of course, considerable enlargement of the glands. It is ushered 
in by a chill, followed by a high fever, and unless arrested in 
its earlier stages, runs a somewhat definite course of from four 
to six days. The exudation in the tonsil overflows the cav- 
it}^ of the follicle, and shows itself on the surface in a number 
of small, round, pearl-colored gray spots. The gravity which 
attaches in the minds of the laity to white spots in the throat, 
oftentimes serves to invest this disease with a danger which 
never attends it. Its tendency is alwaj^s to get well, and its 
progress, although attended with extreme pain and distress, is 
never complicated by any mishaps of a serious character. 

Its early recognition, however, is of importance as enabling 
the physician to give assurance of its harmless character. 
What was said in regard to membranous sore throat is true of 
this disease also, viz., that it is probable that there is a previous 
blood condition, or hyperinosis, which dominates and controls 
the inflammatory process, which results from taking cold, and 
gives rise to an exudation of lymph rather than a simple ca- 
tarrhal inflammation ; and while in membranous sore throat 
this occurs on the surface of the mucous membrane, in the dis- 
ease under consideration it occurs in the cavities of the follicles 
of the tonsil. Hence, what was said of the former disease is true 
also of this ; that the incipient chill and subsequent fever are 
more marked than we should expect to find as purely symptom- 
atic of an inflammation so limited in extent. The chill, as a rule, 



124 DISEASES OF THE FAUCES. 

is quite well marked, though there may be merely chilly sensa- 
tions. This is followed by a feeling of dryness and tickling, or 
irritation in the throat with extreme pain in swallowing. This 
is always a prominent feature of the affection, the pain being 
of a sharp, lancinating, cutting character. The exudation into 
the follicles and their distention, gives rise, of course, to a cer- 
tain amount of pressure on the terminal nerve-filaments, and as 
a consequence, a considerable degree of constant pain referable 
to the inflamed part. This pain is necessarily very much ag- 
gravated by the pressure to which the tonsil is subjected in the 
act of swallowing. The disease may attack one or both tonsils, 
and it may involve the whole tonsil or only a few of the folli 
cles. The general subjective symptoms correspond to an ex- 
tent with the gravity and extent of the inflammatory exuda- 
tion. 

The course of the disease, as was said before, is toward a 
termination in four or five days by an absorption of the exuded 
matter, the subsidence of the swelling and infiltration, and the 
disappearance of fever and all other symptoms. Occasionally, 
in the more aggravated forms of the affection, where the folli- 
cles are greatl}^ distended, there occurs the formation of small 
abscesses, involving one or more follicles and resulting from the 
closure of the follicular orifice, the retention of the exudation, 
and its suppuration. 

On examination there will be found one or both tonsils 
swollen and projecting somewhat from their bed, the mucous 
membrane covering them of a bright, angry red color, and on 
the surface of the tonsil there will be seen from three to eight 
or ten small, round, gra3ish, pearl-colored spots, their borders 
being entirely separate as a rule, though occasionally the exu- 
dation may extend so far that several spots may coalesce, pro- 
ducing the appearance of a small membrane. These spots are 
well marked in the more aggravated cases, and unmistakable ; 
while in others, where but few follicles are involved, and the 
exudation is limited in extent, the spots do not show them- 
selves clearly and distinctly, but are only seen on close exam- 
ination. The crucial test is, that it will be found on using a bent 
probe, that it passes readily and freely through the centre of 
each spot into the large and distended cavity of a follicle. 
This test should always be resorted to where there is any doubt 
as to the character of the exudation. 



ACUTE FOLLICULAR TOISTSILLITIS. 125 

The cause of this affection is fi-om taking cold in a major- 
ity of cases ; and yet behind this there is probably some 
especially predisposing cause of which we are ignorant. That 
it is something in the nature of an essential fever, there is 
good ground for supposing ; yet that it is contagious, I do 
not believe. It often prevails somewhat as an .epidemic and 
also endemically. In cases it has run through a family, at- 
tacking nearly every member ; and yet it is far more liable to 
attack them at nearly the same time than seriatim, in which 
latter case there would be evidence of its being contagious. It 
frequently attacks those worn out and fatigued by overwork 
and loss of sleep ; especially those engaged in caring for the 
sick. I have not infrequently met with it in those engaged in 
nursing children sick with diphtheria ; and in these cases it is 
not uncommon for the attendant to insist that she has contracted 
diphthericj, from the child. There is absolutely no connection 
between the two diseases, and yet a fond mother will often de- 
rive a morbid comfort in the thought that she has contracted 
diphtheria from her child, when she has a follicular tonsillitis ; 
and, moreover, physicians of our own school, as well as the 
other school, often encourage her in the notion and coincide 
with her. 

Treatment. — At the commencement of the attack a full dose 
of quinine should be given, followed by the tincture of iron in 
glycerine, as follows : 

]^ . Tinct. ferri chloridi 3 j. — 3 ij. 

Glycerinse aa 3 ij. 

M. Sig. — One teaspoonful eveiy two hours. 

This should be given without the addition of water ; the 
iron given in glycerine is deprived of much of its disagreeable 
taste, and is made a not unpleasant dose. It acts, probabl}^, 
as a local astringent in passing over the inflamed organ, and 
also exercises a controlling influence on the general condition. 
This mixture I regard as almost a speciflc in the disease un- 
der consideration, as it serves not only to control and cut 
short the duration of the attack, but in most cases from the 
flrst dose given, affords relief to the pain which is often of a 
very acute character. 



126 DISEASES OF THE FAUCES. 

Occasionally additional relief will be afforded by the use of 
astringent lozenges of tannin, lisematoxylon, acidi benzoici, etc. 

Or there may be given potass, chlorat. as follows : 

< 

U. Potass, chlorat., 

Pulv. acacia, 

Sacch. alb aa 3 j. 

M. 

A small portion of tliis taken on the tongue and being dis- 
solved in the saliva, is swallowed slowly and thus comes in 
contact with the diseased part. These remedies are, however, 
of limited value. 

Next in importance to the iron and glycerine, I regard the 
local application of nitrate of silver. This remedy should rare- 
ly be applied to a mucous membrane in a greater strength than 
gr. XX. — IJ., unless it is desired to destroy tissue. In fibrin- 
ous exudation, however, it should be used of a strength of gr. 
xl. — Ix. to 3 j. in order to completely destroy the membrane or 
exudation, and to prevent a recurrence. In the disease under 
consideration it is necessary, in order to reach the site of the 
morbid process, that the application should be made into the 
cavities of the follicles. For this purpose a slender probe 
should be bent at right angles, and with an extremely thin film 
of cotton wrapped on its extremity, and charged with nitrate 
of silver of the above strength, should be passed directly into 
each crypt. The result of this is the destruction of the exuda- 
tion and the prevention of its recurrence. The procedure is 
a very simple one, not attended with pain, and affords much 
relief. 



CHAPTER VIII. 

HTPEBTEOPHY OF THE TONSILS. 

By hypertrophy of the tonsils is meant any abnormal en- 
largement which does not directly depend on acute inflamma- 
tion, or on the growth of any new formation in or upon the 
structure of the gland. The tonsil is enlarged, partially by the 
distention of the follicles by their perverted and degenerated 
secretion, and partially by the hypertrophy of the parenchyma 
of the organ resulting from chronic inflammation. 

The cause of this affection is not always perfectly clear, the 
most frequently assigned cause being repeated attacks of acute 
inflammation, which lead to permanent and additional depos- 
its in the glands. A single acute attack, either simple, as in 
measles, or specific, as in diphtheria, may result in perma- 
nent enlargement of the organ ; or, again, the attack may be 
chronic from the commencement, and the first time attention is 
called to the fauces, the glands are found greatly enlarged. In 
this case, however, it is frequently associated with scrofula or ra- 
chitis, which is said to be a very frequent cause of the trouble. 
Its association with scrofula is easily understood from the an- 
atomical and physiological character of the gland ; but that it 
is, in this country at least, commonly due to the rachitic taint, 
is probably not true, for, whereas, an enlarged tonsil is very 
frequently met with, rachitis is of comparatively rare occur- 
rence. Dentition in children has been asserted to be a cause of 
the affection, as also disturbances of digestion producing tempo- 
rary engorgement of the tonsils, which, frequently repeated, 
may produce permanent enlargement. Among the poorer classes, 
surrounded as they are by bad hygienic influences, living in 
close and ill-ventilated apartments, supplied with insufficient 
or improper food, subjected to exposure, and the vaiious cir- 
cumstances which attend life in the lower strata, and which we 
recognize as powerful factors in the development of that aggre- 



128 



DISEASES OF THE FAUCES. 




'1 



gate of symptoms which we call scrofula, we not infrequently 
meet with enlargement of the tonsils, due directly to these 
causes. 

In most that has been written on this subject, but one form 
of enlargement is described. To my friend Dr. M. D. Mann I 
am indebted for the results of some investigations which he has 
been making on this subject, and my own observation so fully 

coincides with his research, 
that I readily accept his 
statements. He finds that 
anatomically we meet with 
two forms of enlargement 
of the tonsils ; one due to 
an h3^pertrophy of the stro- 
ma of the organ, while the 
other is due to an enlarge- 
ment and distention of the 
glandular structures ; com- 
monly, both conditions are 
more or less associated ; 
one, however, predominat- 
ing over the other, and the 
tonsil will present different 
appearances, according as 
the one or the other pro- 
cess is in the ascendancy ; 
or, again, one process may 
go on almost to the entire 
exclusion of the other. If 
the follicles are the princi- 
j^al seat of the lesion, that 
is, if the epithelial elements 
are involved to the exclu- 
sion of the connective tis- 
sue, and we get a true hy- 
pertrophy of the gland or an increase in the proper gland tis- 
sues (See Fig. 77), we then have an appearance with which 
we are all familiar; the gland is roughened on its surface and 
irregularly nodular ; the follicles being distended, the secretion 
presents at their open mouths, and can be wiped away or pressed 
out ; the glands are soft and friable, and easily transfixed with a 



^ 



\ 



Fig. 77.— a section of the tonsil in a state of true hy- 
pertrophy, showins the enlarged and distended follicles 
with their thickened walls. (Luschka.) 



HYPERTROPHY OF THE TOWSILS, 129 

probe. On the other hand, if the increase in size depends on 
growth and proliferation of connective-tissue elements, a very 
different condition and appearance is produced. The surface 
of the gland is smooth and rounded. If seen in the earlier 
stages of the disease, it is soft and compressible, but in the 
more advanced stage, it is firm and elastic. The follicles are 
compressed and atrophied, their function being abolished. 
There is, of course, an absence of the degenerated and cheesy 
secretion which is so characteristic of the first form of enlarge- 
ment. The latter form of the disease we may call the liyper- 
2?lastic, while the first, from being a true hj^pertroph}^, we de- 
scribe as liypertroiDliic. The hypertrophied tonsil probably 
results from acute attacks of catarrhal inflammation, while the 
hyperplastic tonsil, depending as it does on an increased vas- 
cular supply, with increased growth and cell -proliferation, is 
often the result of the strumous diathesis, and is chronic from 
the beginning. The course of the first, or hypertrophic form, 
is a continuous growth as long as the acute attacks are fre 
quently renewed, and is the form more commonly met with in 
adults. The hyperplastic form, depending as it does on a pe- 
culiar diathesis, is largely confined to children, and commonly 
disappears at puberty. 

The age at which enlargement of the tonsils appears is in 
childhood and youth. It rarely appears before the second or 
third year of life, but during the years of childhood is quite 
common. Many cases disappear at puberty, either by absorp- 
tion of the freshly formed and imperfectlj^ organized connec- 
tive tissue, or by a shrinking or contraction of the connective- 
tissue bands which are too well organized to be absorbed. 
Even if the enlargement does not diminish, if it does not 
increase, after puberty it may cease to be a source of trouble, 
as at that time the throat and fauces undergo a considerable 
development, and tonsils which before puberty might cause 
obstructioii in the throat of the child, become relatively small 
and cease to be an obstacle in the larger and more roomy passage 
of the adult. It is extremely doubtful whether true hyper- 
trophy ever disappears except by excision, or even that it re- 
mains stationary, but more probably it goes on growing in size 
and keeping up the train of symptoms which its presence ex 
cites. As a rule, both tonsils are affected together, and gener 
ally to the same extent, though not infrequently thev differ 
9 



130 DISEASES OF THE FAUCES. 

in size, and even one tonsil may be greatly enlarged while its 
fellow is unaffected. The general tendency of the growth is 
toward the median line, though there is an additional and de- 
cided tendency toward the growth downward, which may go on 
to such an extent that its amount can only be determined b}'' 
the finger or the mirror. It may also extend upward toward 
the Eustachian tube, and produce sj^mptoms with reference to 
the hearing. Adhesion between the tonsils and pillars of the 
fauces are of frequent occurrence. 

The diagnosis, of course, is simple, inspection of the fauces 
being sufficient ; but it should always be borne in mind that 
in the examination, if retching occurs, and consequent contrac- 
tion of the muscles of the fauces, the tonsils are lifted from 
their bed and crowded forward toward the median line in such 
a way that a tonsil with a very moderate enlargement may be 
made to appear of an unusual size. Hence, in making the^ 
examination, a little patience should be exercised, that a view 
of the parts at absolute rest may be secured, in order to form 
a proper estimate of the amount of hypertrophy that really 
exists. 

Prognosis. — From what has been said before it will be 
easily inferred that the prognosis depends somewhat on the 
character of the enlargement, the age of the patient, or the 
duration of the trouble. If the growth is glandular in its 
nature, that is, if true hypertrophy exists, assurance may be 
given with absolute certainty that it will not disappear under 
medication or local api^lications, but that the only remedy for 
the disease is the complete removal or des traction of the 
organ. If, on the contrary, we find an hyperplastic growth, 
and we see the case in the early stages, we may hoj^e by 
pro]3er medication to arrest the progress of the disease, and 
accomplish the absorption of the already effused material. If 
the case is quiescent and near the age of puberty, we may 
anticipate with considerable confidence the disappearance of 
the tonsil with the appearance of the usual growth that occurs 
at that period, provided the general health is not impaired. If 
we find, however, as we do in so many of these cases, that 
under the influence of impaired or insufficient aeration of the 
blood, broken sleep, disturbed digestion, etc., due unquestion- 
ably to the enlarged tonsil in many cases, that the general 
health is failing, the operation will be necessary and even im- 



HTPEETROPHY OF THE TONSILS. 131 

perative. Again, if the patient is an adult, and tlie disease 
has existed from childhood, no hope of relief, can be afforded 
save by an operation. 

Symptoms. — If the tonsils are but moderately enlarged, the 
sj^mptoms are not marked ; perhaps nothing more than a 
moderate degree of secretion from the fauces, with a disposi- 
tion to take cold easily, which manifests itself in an ordinary 
sore throat. The greater degree of enlargement, however, 
gives rise to a train of symptoms which often fail of recogni- 
tion as connected with this disorder. 

The peculiar voice of a patient with enlarged tonsils is fa- 
miliar to all ; it is thick, with a half-muffled character, together 
with an absence of any nasal twang. This character of the 
voice is due partiall}^ to the closure of the palato-pharyngeal 
space by the encroaching tonsils, and partially to their inter- 
ference with the free movement of the palate, and also with the 
play of the tongue which is necessary to a clear and healthy 
tone of voice. 

Snoring is another constant symptom of the disease. The 
breathing space in the fauces is so far encroached ujDon, that 
the patient involuntarily opens the mouth during sleep, and 
respiration is accomplished through both the nose and mouth, 
whereby the soft palate and uvula are thrown into vibration, 
giving rise to that disagreeable sound which we call snoring. 
This may accompany both inspiration and expiration, though 
as a rule it belongs to inspiration. 

Dr. Haward, of London, first called attention, in 1873, to 
the frequent occurrence of nightmare in this affection, explain- 
ing it by the fact that the narrowing of the fauces so far inter- 
feres with respiration as to prevent perfect aeration of the 
blood, causing cerebral congestion and consequent disturbed 
functional activity. During waking hours this deficiency is 
compensated ; the deficiency in the blood being counterbal- 
anced by the increased respiratory effort, the ^^hesoin de 
resp'rer'''' giving rise to increased muscular activity. During 
sleep, on the other liand, this voluntary aid to respiration is 
witlidrawn, and involuntary respiration fails to supply the 
blood with oxygen. As a result of this, the carbonic acid 
accumulating in the blood, the lung circulation is clogged, 
and consequently the functional activity or disturbed brain 
action ensues, taking the form of the familiar phenomenon of 



132 DISEASES OF THE FAUCES. 

nightmare. A peculiarity of nightmare in enlarged tonsils is, 
the tendency to recurrence of the attack several times in the 
same night,"^ and this is peculiar to this disease alone ; the 
nightmare of indigestion or dentition rarely if ever occurring 
more than once in the same night. We see an exemplification 
of this in many cases of puhnonary, cardiac, and laryngeal dis- 
eases, where involuntary muscular effort is insufficient to carry 
on respiration, and sleep is sacrificed to the necessity of re- 
maining awake, for the sole purpose of keeping in play the 
involuntary muscles of respiration in order to preserve life. 

A slight liacking congh is often noticed in enlarged tonsils, 
and is due to the fact that the patient opens the mouth to 
breathe while asleep, and as a consequence, the parts become 
dry, parched, and painful, and hence an irritating cough sets in. 
Deglutition is interfered with by the diminution of the ca- 
pacity of the fauces, and also by the mechanical interference 
with the free action of the muscles concerned in propelling the 
food into the oesophagus. There is a tendency to renewed 
catarrhal attacks ; that is, a patient with enlarged tonsils takes 
cold on a very slight provocation ; as a result of which, the 
previous symptoms are markedly aggravated, particularly the 
difficulty in deglutition, owing to the tenderness of the in- 
flamed organ. In 1838 Dupuytren called attention to a pecu- 
liar deformity of the chest which he found in connection with 
hypertrophied tonsils, and which he regarded as the direct 
result. This deformity consists in a peculiar bending of the 
ribs, by which the sternum is forced prominently forward, and 
the 'chest compressed from side to side, the antero-posterior 
diameter bearing a close relation to the lateral, and producing 
what we call pigeon-breast. Dr. Shaw, of London, published, 
in 1841, a very ingenious explanation of this deformity, which 
was as follows : The isthmus of the fauces is so far narrowed 
as to prevent sufficient entrance of air ; the hesoin de respirer 
becomes very great ; the respiratory muscles are brought into 
vigorous action ; the,ribs are elevated, but not sufficiently to al- 
low of free access to the lungs ; a vacuum or a tendency to a 
vacuum is created between the sides of the lung and the chest- 
wall laterally ; to fill this vacuum, the ribs are bent, and sink 
in at the sides, forcing the sternum forward. This explana- 
tion is a plausible one, but it seems difficult to accept the 
ori.D-inal theory, for we can scarcely realize any obstruction in 



HYPERTROPHY OF THE TONSILS. 133 

the fauces sufficient to produce tlie deformity unless tliere had 
ah'eady existed coincident softening of the ribs. We should 
then be led to the conclusion that rickets already existed, and 
knowing, as we do, how commonly rachitic children suffer 
from enlarged tonsils, we may reasonably conclude that the 
enlargement of the tonsils and the chest deformity are due to 
a common cause. The same is true of the dilatation of the 
anterior nares, sometimes attributed to pressure of the en- 
larged glands. 

If respiration is interfered with of course the supply of 
oxygen is curtailed, and oxygen is not only the great agent 
of respiration, but is the great stimulant or excitant of nutritive 
action ; consequentlj^, as a result of enlarged tonsils, we may 
look for more or less impairment of nutrition ; the mere pres- 
ence of the disease in the fauces being sufficient to account for 
symptoms which indicate impairment of the general health. 
The follicles are filled and distended by what, when it is first 
poured out, is comparatively healthy mucus, containing epithe- 
lial cells. This secretion, however, remaining in the follicles, 
undergoes decomposition, and becomes, to an extent, putrid. 
As the processes go on by which this matter is deposited under 
the influence of successive exacerbations, acute in character, 
the decomposed material presents itself at the mouths of the 
follicles and is swept into the stomach with the food. 

This condition also serves to vitiate the inspii'ed air, which 
in passing over it becomes to an extent impregnated with 
the fetid emanations which have their source in the putrid 
masses. As a result of this, continued as it often is over a long 
period of time, it is not surprising that the general health, 
which may have been robust in the earlier stages, finally suc- 
cumbs. We may have also the still further symptom of anae- 
mia ; this is the direct consequence of the disease. Its mode of 
development, with its usual symptoms of pallid face, pali^itation 
of the heart, shortness of breath, etc., needs no further explana- 
tion. But going still further, I recall in my experience several 
cases in which the sequence of events could be traced to en- 
hirgement of the heart by dilatation, due unquestionably to 
hypertrophy of the tonsils, of long standing. As we know, 
tlie first muscle of the body to receive its blood-supply is the 
busiest, viz., the heart ; it is also the quickest and most sensi- 
tive to feel the deficient quality of the blood-supply it receives ; 



134 DISEASES OF THE FAUCES. 

it is weakened as the result of insufficient nourishment and also 
by the additional labor of pumping impoverished blood through 
the arteries, which, as we know, flows with more resistance 
through the circulatory system than healthy blood. In the 
disease, then, under consideration, the general health and blood 
becoming impaired, the heart is quick to feel the additional 
labor upon its already weakened walls, and yields to hyper- 
trophy by dilatation. 

Spasm of the glottis often occurs in enlarged tonsils, but 
here, as in pigeon-breast, the relation of cause and effect is not 
evident, as the best modern writers attribute spasm of the 
glottis to rickets, and hold that this is due to irritation of the 
brain caused by craniotabes. It seems more probable that the 
two diseases are due to a common cause, rather than that there 
is any genetic connection between the two. Impairment of 
hearing, with tinnitis aurium, is often met with in connection 
with this affection ; this is due in part to pressure on the open- 
ing of the Eustachian tube, and in part to thickening of the 
mucous membrane, resulting from the catarrhal condition 
which often accompanies enlarged tonsils. To whichever of 
these conditions the impaired hearing may be due, a removal 
of the gland is always attended with a marked improvement, if 
not its total restroration ; and if it is the mucous membrane 
alone which is at fault, the removal of the gland is imperative, 
in order to obtain free access to the diseased part, for its proper 
examination and treatment. 

Treatment. — This must depend upon the cause, nature, and 
stage of the disease, in the particular case with which we have 
to deal. If the patient is young, and the enlargement slight 
and of short duration, no treatment other than a proper pro- 
phylaxis against further enlargement will be necessary. If we 
have to deal with a case where the scrofulous or rachitic dia- 
thesis exists, and the trouble has not existed too long, we may 
hope to remove the enlargement, as we do many other glandu- 
lar enlargements met with in these conditions, by proper con- 
stitutional measures. Iron, cod-liver oil, iodine, both internally 
and locally, the lacto-phosphate of lime or arsenic, conjoined 
with proper hygiene, will do ^11 that can be done, and will for- 
tunately often be successful. If the enlargement is due to re- 
peated catarrhal attacks, we can at best only hope by careful 
prophylactic measures to arrest the further progress of the dis- 



HYPERTEOPHY OF THE TOISTSILS. IBS 

ease. Showering tlie neck with cold water serves to render the 
surface less susceptible to the influence of cold, and diminishes 
the number of attacks. 

As local remedies, there are few of the many astringents 
in the whole pharmacopoeia but have been recommended. As 
a simple astringent, nearly free from irritating qualities, a sat- 
urated solution of tannin, either in water or glycerine, is excel- 
lent. This should be applied twice a day over the whole gland, 
and in many cases will accomplish much good. Of the min- 
eral astringents, nitrate of silver, ten to twenty grains to the 
ounce, is the best ; for in addition to its astringent action, it 
possesses the property of promoting absorption. Gargles of 
alum, chlorate of potash, or borax, may be used with some ben- 
efit. For promotion of absorption, the use of the preparations 
of iodine promises the best results. In true glandular hyper- 
trophy we cannot hope for much benefit, but in the hyper- 
plastic form of enlargement, iodine used locally will oftentimes 
serve to produce a shrinking of the gland. In using iodine it 
should be borne in mind that the simple tincture is insoluble in 
water ; the compound tincture, however, is freely soluble. In 
this form, then, the iodine can be taken up by the absorbents, 
and penetrating deeply into the tissues, materially affect the 
disease. Other drugs in common use are iodide of potash, muri- 
ate of ammonia, and iodide of ammonium ; their administration, 
however, is extremely uncertain in its results. Guiac internally 
administered is said to possess a most satisfactory action, in 
removal of enlarged tonsils. I have never seen anj^ good result 
from its administration. 

If astringents and absorbents fail, and in a very large 
majority of cases they do fail, the only resort remaining is 
removal of the gland by caustics or the knife. The mineral 
acids, nitric and muriatic, have been used for the destruction 
of enlarged tonsils ; both are very violent in their action, and 
it is extremely difficult to limit it. As regirds nitrate of 
silver, it is very slow in its action, and forms an insoluble 
compound with the albumen of the tumor, an albuminate of 
silver, hence its action is extremely limited. The alkaline 
caustics are preferable, from the fact that their compounds 
with albumen are soluble in water, and therefore they extend 
their action much more deeply into the tissues ; the difficult}'- 
with them is in limiting their action. Dr. W. J. Smith, of 



136 DISEASES OF THE FAUCES. 

London, overcomes this difficulty by using a small platinum 
disk, mounted on a handle ; pn this he fuses the layer of 
caustic and holds the surface in contact with the gland for 
a moment at a time, accomplishing its complete destruction 
in six or seven sittings. Mackenzie, of London, uses Lon- 
don paste and claims very successful results. Donaldson, of 
Baltimore, makes small incisions into the tonsils and inserts 
crystals of chromic acid. As regards the destruction of en- 
larged tonsils by any of the various caustics, it may be said 
that it is a tedious and painful procedure, and as a rule should 
only be resorted to where there is good reason, contraindicat- 
ing the use of the knife. Their excision on the other hand is 
simple, speedy, comparatively painless, easily accomplished, 
attended with no danger in the vast majority of cases, and in 
every respect so much to be preferred to the use of caustics, 
that there should be little question with regard to its adoption. 
When, therefore, we meet with a case which will not jield to, 
or which has gone beyond the condition which yields to the 
simple remedies before spoken of, and which demands destruc- 
tion or removal, and under this head we may class all cases 
of true hypertrophy and a large proportion of cases of hyper- 
plastic enlargement, my preference is very decidedly in favor 
of the use of the knife. This should be done immediately and 
without delay, unless there exists some concurrent inliamma- 
tory condition of the fauces, such as ordinary catarrhal sore 
throat, which occurs so often in connection with enlarged ton- 
sils ; if this exists, the operation should be delayed until the 
attack subsides, simpl}^ for the reason that it increases and 
aggravates the inflammatory trouble, and also that the inflam- 
mation resulting from the operation, usually unappreciable, is 
liable to be much aggravated. Aside from this consideration, 
there is no good reason for delaying the operation. Delay will 
oftentimes be urged, on the ground that the j^atient is too weak 
and delicate, and that time should be afforded for a course 
of tonic treatment, a building-up process, to enable the sufferer 
to better endure the operation. The operation itself is so ex- 
tremely simple and painless that no preparation is required ; 
and, furthermore, for the weak and delicate condition that 
exists, the best tonic that can be adjjiiinistered is the removal 
of the gland, allowing thus the free access to the lungs of an 
abundance of pure air. As regards the dangers of the opera- 



HYPERTROPHY OF THE TONSILS. 



137 



tion there is but one that needs be alluded to, and that is hem 
orrhage. This unquestionably has been much over-estimated 
In the very large number of tonsils removed by my- 
self, both in children and adults, I have never met 
with a single case of troublesome hemorrhage. M. 
Guersant says : "I have operated on a thousand chil- 
dren, and have only seen formidable hemorrhage in 
three cases." In many cases of hemorrhage the gravi- 
ty of the accident has been greatly exaggerated b}^ in- 
judicious and nervous interference. Dr. Lefferts, of 
this city, had an experience which is so extremely in- 
structive that I am induced to relate it in full. 

He removed the tonsils from a young man at the 
Demilt Dispensary, and no hemorrhage appearing, 
left for home. Soon after reaching his office, at the 
end of an hour, he received a summons to hasten back 
to the dispensary as his patient was bleeding profusely. 
On returning, he found the man ver}'" much exsangui- 
nated and weakened from loss of blood, and the fau- 
ces filled with a mass of blood and persulphate of iron. 
He learned that soon after his departure liem orrhage 
came on, and that the assistant immediately resorted 
to the use of iron in his efforts to control the bleed- 
ing, and with the usual result ; he heaped layer upon 
layer of iron and coagulated blood upon the bleeding 
surface, but failed to stop the hemorrhage. Dr. Lef- 
ferts immediately cleared out this mass, and cleaning 
the cut surface found a small artery spurting. He 
seized it with torsion-forceps, twisted it, and the hem- 
orrhage was over. The deduction is manifest. If ar- 
terial hemorrhage occurs, its source, as a rule, is from 
the tonsillar artery, and the first effort should be to 
seize the bleeding vessel ; if, however, the hemorrhage 
is moderate, it can be relieved by simple pressure, 
either with the finger covered with a napkin, or with 
a pledget of cotton wool wrapped on a probe or held 
in forceps and pressed against the part. As regards 
the operation, it may be done with a probe-pointed 
bistoury (Fig. 78), or with one of the tonsillotomes 
especially devised for the purpose. If the bistoury is used, the 
tonsil should be seized with a pair of forceps ; or, better still, 



Fia. 78.— 
Tonsil bis- 
toury. 



138 



DISEASES OF THE FAUCES. 



with tlie vnlselliim shown in Fig, 79, or some similar instrn- 
ment, and being lifted somewhat from its bed, cut by two or 
three rapid sweeps of the knife. This requires, of course, that 
the operator should be ambidextrous, as in the 
removal of the right tonsil the cutting is done 
with the left hand and mce versa. I much prefer, 
however, the tonsillotome, in that the operation 
is quickly and rapidly done ; it avoids the possi- 
bility of the knife cutting parts other than those 
it is designed to cut ; and it renders absolutely 
impossible the cutting of the carotid artery, which 
is one of the supposed dangers in excision of the 
tonsils. It is often said, in regard to the opera- 
tion, that the o\\\j truly surgical method is in the 
use of the bistoury. It is not possible, as a rule, 
to cut with precision ; there is danger of cutting 
the pillars of the fauces and thereby impairing the 
T^su function of deglutition, and the procedure may be 
prevented or rendered extremely difficult by the 
movements in the fauces or the struggles of the patient. Fur- 
thermore, in cutting with the bistoury, the operator will require 
four hands, one for the vulsellum, one for the bistoury, one 
for the tongue depressor, and one to hold the head of the 





Fig. 80.— Mackenzie's modification of Physick's tonsDlotome. 

patient. If these were at his service, the operation would be 
a more commendable one. In the use of the guillotine, on the 
other hand, the operation is unattended with any of the above 
dangers and objections. The pillars of the fauces or the uvula 
cannot easily be injured, and, furthermore, the operation is 



HYPERTROPHY OF THE TOI^SILS. 



139 



easily done by the use of two hands, one holding the instru- 
ment, while with the other hand the jaw of the patient is 
seized, and the head held firmly and steadily until the opera- 
tion is finished. 

The original idea of a guillotine for removing the tonsil was 
the instrument of Physick, which consisted in a simple plate 




Fig. si. — Fahnestock's tonsillotome. 

containing an oval fenestrum on which there played a knife. 
This has been somewhat modified by Mackenzie, as shown in 
Fig. 80. Subsequently Fahnestock added a sliding stylet for 
piercing the tonsil before amputating it, by which it is pre- 
vented from falling into the air-passages. (See Fig. 81.) An ad- 




FlG. 82, — Improved German tonsillotome. 



ditional improvement was made by which the mass is not only 
seized, but raised from its bed before cutting. This is shown 
in a German instrument. (See Fig. 82.) In this instrument the 
movement for raising the mass is automatic. Hamilton has 
further modified the guillotine by mounting the seizing forceps 



140 



DISEASES OF THE FAUCES. 



on a freely movable hinge- joint, in such a manner that the 
mass can be grasped, and by a to-and-fro movement worked 
thoroughly into the fenestrum before cutting. (See Fig. 83.) 

Mackenzie has devised a double tonsillotome, shown in Fig. 
84, by means of which both glands can be removed at the same 
instant. This may be desirable at times in the case of a ner 




Fig. S3.— Hamilton's tonsillotome. 

vous or excitable patient, but, as a rule, the single operation 
and instrument will be preferred. 

"When the instrument is introduced into the mouth the 
blades must be in the centre, but on grasping the two handles 
too-ether, the blades are thrown out against the sides of the 




Fig. 84.— Mackenzie's double tonsillotome. 



throat, and the tonsils received in the oval openings of the ton- 
sillotome. Amputation is then effected by pressing on the ring 
at the proximal extremity of the instrument in the usual way" 
(Mackenzie). 

It will be noticed, in regard to all the above instruments, that 
the longest diameter of the fenestram is from before backward. 



HYPERTROPHY OF THE TOTSTSILS. 



141 



This is a radical defect, in tliat tlie longest diameter ol an liy- 
pertropliied tonsil is invariably tlie vertical one. Hence, it will 
often be difficult to adjust any of these guillotines in such a 
mariner as to include the whole gland, unless it be but mod- 
erately enlarged. Fig. 85 illustrates 
Mathieu's tonsillotome, with the method 
of holding it. I regard this as by far the 
most perfect instrument yet devised. 
As will be noticed, the long diameter 
of the fenestrum is the vertical. By 
this instrument the tonsil is first pierced 
by the fork and raised from its bed, and 
then the knife is drawn home, the whole 
operation being completed by a single 
movement of the hand. In operating 
with Mathieu's instrument it is w^ell to 
seize the lower jaw of the patient be- 
tween the thumb and two fingers, a tow- 
el being interposed, thus securing com- 
j)lete control over his movements. The 
instrument is then passed, with the fork 
side downward, back until the fenestrum is 
opposite the tonsil, using the instrument 
itself as a tongue depressor, when by a 
quick turn of the hand it is rotated upon 
the organ from below upward, and the 
operation rapidly completed. Of course 
the head-mirror should be used to afford a 
sufficient illumination. The great defect in 
many of the tonsillotomes lies in their fen- 
estra being too small. It is well to have 
several sizes, but as the general practitioii- 




FiG. 85.— ilnthii 



ment, care should be exercised in tlie si^- 
lection of one with a large fenestrum. 

It is often asserted that, if but a part of 
the tonsil is excised, the remaining portion will atrophy; this 
is partially true only. If the distended crypts are cut through 
they will shrink up to a great extent, but there will remain 
the mass of the base of the h^^pertrophied organ, wdiich is bet- 
ter away. The whole of the organ should be removed if pos- 



142 DISEASES OF THE EAUCES. 

sible in all cases, so completely that the pillars of the fauces 
will fall into their normal j)osition, and that all vestiges of the 
tonsil, may disappear. This cannot always be accomplished, 
but where it is possible it should be done. Certainly it is a 
mistaken idea to su23pose that it is well to allow a part of the 
organ to remain to fulfil any function that it possesses in the 
economy. Practically the tonsil does not exist in health. After 
the removal of the gland by the guillotine there will occasion- 
ally be left small masses, or fragments, which can easily be 
removed by means of a pair of forceps, with the bistoury, or 
long scissors. 

A condition of enlargement of the tonsil is frequently met 
with in which, on account of its broad flattened shape, it can- 
not be engaged in the fenestrum of the guillotine, and hence, 
cannot be excised by the ordinary manipulation of that instru- 
ment. In these cases I still regard the use of the tonsillotome 
as the best method of removal of the gland. The instrument 
having been placed in position, a tenaculum or vulsellum (Fig. 
79) should be used to drag the tonsil from its bed and into the 
fenestrum, when the operation is easily completed. Hamilton's 
instrument (Fig. 83) is especially designed to meet these cases, 
but an unattached vulsellum will be found to be more easily 
managed. 



CHAPTER IX. 

SYSTEMIC DISEASES OF THE PHAEYNX. 
Syphilis of the Phaeynx. 

The manifestations of constitutional syphilis which are met 
with in the fauces, are catarrlial pliaryngitis, mucous patcJies, 
superficial ulcerations, and deep ulcerations. Under the latter, 
however, it should be understood that there is included the 
deposit of gummy tumors, but in this situation they undergo 
such rapid progress into the ulcerative stage, that it is a matter 
of the extremest rarity to meet with them previous to the de- 
velopment of the destructive process. Occasional references 
are found, in the literature of syphilis, to the occurrence of 
phagedgena in the fauces ; I think the nearest approach we 
find in this region to phagedsenic action, occurs in the deep 
ulcerations resulting from gummy tumors, as their destructive 
progress is often quite rapid ; but that this ever constitutes 
genuine phagedsena is open to question. 

The extensive cicatrices and great deformities in the fauces, 
resulting from syphilis, are due to the deep ulcerations, and 
hence will be noticed under that head. 

Cataeehal Phaeyngitis of Syphilis, oe Oedinaey Syph- 
ilitic SoEE TiiEOAT. — This manifestation of constitutional 
syphilis may occur as early as three or four weeks after the 
primary sore, or it may be delayed several months. It consists 
in the development in the mucous membrane of the fauces, as 
the result of the blood poison, of an acute catarrhal inflamma- 
tion, involving the posterior wall of the lower pliarynx and ex- 
tending to the pillars of the fauces, the soft palate, uvula, and 
tonsils. This is the condition often described as erythema of 
the fauces. The term chosen seems prefei-able, in that there 
exists a genuine catarrhal inliammation of the mucous mem- 



144 DISEASES OF THE FAUCES. 

brane, characterized by redness, swelling, and hypersecretion. 
The appearances are much the same as those which Ave meet 
with in an ordinary sore throat of a non-specific origin. The 
membrane is active!}^ congested, of a bright red color, and 
generally coated with a thin, semi-translucent mucus. The 
tonsils are somewhat swollen, and project from their bed be- 
yond the pillars of the fauces. The uvula is sw^ollen, and of 
a humid or water}^ appearance. The inflammatory process 
extends somewhat in front of the anterior pillars and involves 
the soft palate as far as its junction with the bony portion, 
wdiere it seems to terminate abruptl}^ in a well-defined line of 
demarcation. This appearance is not constant, and yet it is 
very frequently noticed ; and wliile, as a rule, a syphilitic sore 
throat presents nothing b}^ wliicli w^e can distinguish it from 
an ordinary sore throat by mere ocular inspection ; yet in this 
feature, if present, we often possess an aid to diagnosis, and 
one which should always lead to the suspicion of a specific 
origin for the attack. In simple catarrhal pharyngitis, it 
should be remembered, the inflammatory process shades off 
gradually into the healthy membrane beyond. 

Of course if the sore throat comes on in connection with a 
secondary eruption on the skin, an alopoecia or other specific 
manifestation, the diagnosis will be rendered comparatively 
easy ; but probably, in a majority of cases, this does not occur 
at the onset of the attack ; but in a short time these will make 
their appearance, and the source of the faucial affection will 
be made clear. The subjective S3'mptoms which attend the 
attack are those of the non-specific affection, and consist 
mainly in a sense of soreness and irritation about the fauces, 
some pain in deglutition, a feeling of fulness in the fauces, and 
a disposition to hawk and clear the throat, etc. 

The treatment consists in the use of such local remedies for 
the relief of the subjective sj^raptoms as have been noticed in 
the article on ordinar}^ sore throat ; in addition to these, there 
should be given mercury, internally. It has been the experi- 
ence, probabl}^, of most of us, that mercury given for the cure 
of sjqDliilis before any of the secondary manifestations have 
made their appearance, is of little avail in jDreventing their 
development. If the s}' stem has been infected by the chancre, 
the roseola or some other secondary eruption will appear, 
whether mercurj^ has been given or not. Upon the appear- 



SYPHILIS OF THE PHARYNX. 145 

ance of the secondary eruption, however, whether on the skin 
or in the fauces, the drug should be given under the rules 
which govern the treatment of any case of constitutional 
syphilis. We possess no more efficient form than the bichlo- 
ride, given in doses of gr. ^\ three times daily. If the medicine 
acts on the intestinal canal too freely, a small amount of 
opium should be combined with it. This treatment must be 
followed up for twelve months or more, occasionally intermit- 
ting the administration of the remedy for one or two weeks, 
and gradually reducing the dose after the first month, giving 
gr. 3V5 ancl then gr. -^-^, etc. 

Mucous Patches. — This is another of the secondary mani- 
festations of S3^philis, the most frequent location of which is 
on the vulva and anus ; its next most frequent site is in the 
fauces. It has been truly said of mucous patches that they 
are the first to come and the last to go. They may make their 
appearance from three to six weeks after the primary infection, 
or at any time during the history of the disease. A very large 
number of cases of sjqohilis will present the history of repeated 
and recurring attacks of mucous patches during the whole of 
their progress. These patches consist in an infiltration of the 
mucous membrane, in its superficial layer, with lymphoid cells 
which give it a whitish-gray, opaline appearance, very closely 
resembling the appearance produced by touching the part with 
nitrate of^silver. If seen in its very early stages the patch 
shows itself as a faint bluish- white. opacity in the membrane. 
As it progresses, this appearance deepens, and it becomes of 
a denser or grayish-white color. It soon extends laterally, be- 
comes thicker, and is raised above the surface. If it appears 
in any position where the mucous membrane is reflected it may 
become fissured, as at the angle of the mouth or at the root of 
the tongue. Occasionally, when lying in an exposed position 
and subjected to the irritation of the movement of the parts, it 
may become ulcerated, the ulcer presenting the appearances 
of the ordinary superficial ulceration of the earlier stages of 
syphilis. The favorite localit.y of the mucous patch in the 
fauces is on the surface of the tonsil ; rarely on the posterior 
wall of the pharynx. Its next most frequent site is on the pil- 
lars of the fauces, extending to the soft palate and uvula, form- 
ing a chain, as it were, along their border. It is also found fre- 
quently on the sides of the tongue and the inner surface of the 
10 



146 DISEASES OF THE FAUCES. 

cheeks. The moderate amount of secretion from its surface is 
highly infectious, perhaps more so than that of any of the 
secondary lesions of syphilis. A very frequent and noticeable 
characteristic of these patches is their symmetry when dis- 
played on the pillars of the fauces or tonsils. This is due to 
the fact that the parts are brought into apposition during the 
act of deglutition, and that a mucous patch that appears on 
one side of the fauces, stamps itself in perfect and symmetri- 
cal outline on the opposite side, with which it comes in con- 
tact during this act. 

When the patch is confined to the tonsil, it requires a nice 
discrimination sometimes to determine its character. The ton- 
sils are frequently somewhat enlarged and the face of an hy- 
pertrophied tonsil oftentimes will present the grayish and 
slightly mottled appearance of the mucous patch. It is very 
rare, however, to meet with a patch on the tonsil which does 
not extend somewhat to the pillar of the fauces, reflected 
from the side of the gland, and a close inspection will suffice 
to reveal the disease on the mucous membrane of the ante- 
rior pillar. The resemblance also of the mucous patch to 
the appearance produced by the action of caustic should be 
borne in mind. I have more than once been consulted by pa- 
tients presenting every appearance of a mucous patch in the 
fauces, but, on inquiry, learning that caustic had been used, 
have been compelled to defer an opinion until one or two days 
had elapsed, when, of course, if the appearance was a mucous 
patch, it would still remain at the end of that time, but if due 
to caustic application it would disappear. Another appearance 
which is very frequent when these patches occur on the pillars 
of the fauces, is caused by a certain amount of irregular thick- 
ening to which they give rise in the membrane. This appear- 
ance is that of a finely scalloped border which each pillar pre- 
sents, instead of the sharp straight edge presented when the 
mucous membrane is in a healthful condition. Wherever 
found, they are, as a rule, irregular in outline, somewhat mot- 
tled in appearance, the infiltration not extending equally over 
a given portion ; there is no sharp line of demarcation, and the 
mucous membrane surrounding them is healthy in appearance 
and but slightly congested. The prominent subjective symp- 
tom connected with them is that of pain. They always give 
rise to more or less discomfort, and if seated in the fauces the 



SYPHILIS OF THE PHARYNX. 147 

act of deglutition is often extremely painful, the pain being of 
a sharp, prickling character. 

Treatment. — In addition to the general treatment for the 
specific disease, local applications are always required, the ob- 
ject being their complete destruction. For this purpose nitrate 
of silver, nitric acid, and acid nitrate of mercury may be used. 
Where, however, the patch is recent, and limited in extent and 
depth, a sixty-grain solution of nitrate of silver may be used ; 
ordinarily, however, the solid stick will be required. 

The thorough cleansing of the surface of the patch by the 
sponge, or better still by the spra}^, with a solution of carbolic 
acid and borax, adds very greatly to the efficacy of the caustic. 
The application should be made daily. The infectious charac- 
ter of these patches should always be borne in mind in destroy- 
ing them, especially if located in the fauces, as the manipula- 
tion of the parts is liable to excite a sudden cough, which may 
throw some of the infectious matter into the eye or other dan- 
gerous locality. More than one case has been reported in 
which grave results have followed this accident, as chancre of 
the cornea, resulting in loss of sight and constitutional syphilis. 

Superficial TJLCERATioisrs. — This manifestation of syphilis 
in the pharynx occurs as early as three months after the pri- 
mary infection, or as late as three or four years, and consists 
in the development in the mucous membrane of an ulcerative 
process, somewhat limited in extent, of moderately active de- 
structive tendencies, and of a superficial character. It may 
commence in, or result from a mucous patch, when so situated 
that it is exposed to especial irritation, though, as a rule, it 
commences as a superficial erosion, which, progressing some- 
what rapidly, develops into an active, ulcerative process. Its 
favorite locality is on the wall of the low^er pharynx, near the 
posterior pillars of the fauces, or on one of the pillars. Some- 
times we find it on the tonsil, or in the angle of the faucial pil- 
lars above the tonsil, and more rarely on the soft palate or 
uvula. It is generally rounded in outline, and elongated ; pre- 
senting a grayish-yellow surface, which is not markedly de- 
pressed below the surface of the mucous membrane surround- 
ing it. The edges are somewhat sharply outlined, the mucous 
membrane surrounding it slightly reddened, but rarely to the 
extent which characterizes the areola of the tertiary ulcer. The 
secretion from its surface is limited in extent and purulent in 



148 DISEASES OF THE FAUCES. 

character. These ulcerations are not necessarily painful ex- 
cept when impinged upon by the bolus of food, or irritated in 
the act of swallowing. 

Treatment. —In addition to the general treatment required 
in these cases by mercury, local treatment should always be 
resorted to and followed up faithfully and persistently, in 
order to arrest as soon as possible the destructive progress of 
the ulcerative action, the ulceration oftentimes involving parts 
where loss of tissue may lead to serious impairment of their 
function, as When situated on the soft palate or uvula, pillars 
of the fauces, etc. Heretofore, the treatment of these ulcera- 
tions has been mainly by destructive measures, as nitrate of 
silver, nitric acid, and the various caustics, including the gal- 
vano-cautery and actual cauter}^ This treatment is not only 
extremely painful, but also involves an additional loss of 
tissue, over and above that caused by the ulcer ; a waste of 
tissue, by the means employed to cure it. In iodoform we 
have a remedy whose specific action in arresting the progress 
of these ulcers leaves nothing to be desired. It is entirely 
painless, it is not a destructive agent, and by its mere presence 
on the surface of an ulcer it seems to change the wasting pro- 
cess to a reparative one. It may be applied pure, or it may be 
mixed with morphine and tannin, according to the formula 
given in the appendix. The surface of the ulcer should always 
be thoroughly cleansed before the powder is applied : this can 
be done with a sponge, the probang, or the spray ; any simple 
cleansing solution being used, as solution of common salt, car- 
bonate of soda, carbonate of potash, to which, also, carbolic 
acid may be added. There is no better solution, however, than 
that given in the appendix (Prescrij^tion No. 1.). The applica- 
tion should be made every da}^, or every second day, until the 
character of the ulceration is entirely changed, and its surface 
is seen to be covered with healthy granulation-tissue. 

Teetiary or Deep Ulcerations. — In the latter stages of 
constitutional syphilis, extending over a period of from four 
to twenty j^ears after the primary infection, but occurring, in 
the majority of cases, between the seventh and tenth years, we 
meet with a class of ulcerations of the fauces, which present 
entirely different characteristics from those previously de- 
scribed. They are more virulent in character, more rapid in 
their destructive progress, and extend, not only laterally, but 



SYPHILIS OF THE PHARYNX. 149 

deeply, involving oftentimes very grave and serious results, 
merely from the amount of tissue destroyed. They are also 
characterized by the very extensive contractions which result 
from their cicatrices. 

In a very large majority of cases, if not in all, they are due 
to the deposit of gummy tumors in the deep layers of the 
mucous membrane, which, breaking down, rapidly develop 
into ulceration. This ulceration, resulting from a gummatous 
deposit, develops so speedily, that it is extremely rare to see 
a case before the ulcerative process has set in. This deposit 
occurs in the cellular tissue, or submucous tissue, in the shape 
of small, rounded nodules, either singly or in groups ; as a 
rule, however, they form rather extensive masses. Occurring 
in the skin and other tissues, these gummy tumors may remain 
weeks, and even months, without ulceration, while in the 
fauces, as before mentioned, they run on into the ulcerative 
process, oftentimes in a very few hours ; hence, when our 
attention is first called to the throat, we find the destructive 
process fully developed, and oftentimes considerably extended. 
The new material deposited in the deep layers of the mem- 
brane commences to soften and break down in the centre, and 
this process making its way to the surface, gives rise to the 
characteristic appearance of the tertiary ulcer. It has a sharp 
cut, somewhat jagged and overhanging edge ; the surface of 
the ulcer is depressed ; the mucous membrane is excavated ; 
and it is covered with a grayish-yellow purulent discharge, 
and also presents, oftentimes, a slightl}^ gangrenous aspect, 
sloughy shreds or masses of necrosed tissue being discharged 
with the pus. The walls of the excavation present also a 
jagged and sloughy aspect. The mucous membrane surround- 
ing the ulcer is inflamed to a considerable extent, and presents 
an appearance which is characteristic and x^eculiar. It is 
actively and acutely inflamed, markedly congested and 
swollen, and has an appearance which resembles no other dis- 
coloration of the mucous membrane of the fauces, and once 
seen, is always remembered. It may be described as a coppery 
hue, in connection with the angry -looking, beefy red of acute 
inflammation. 

This appearance, or discoloration, of course, is most marked 
near the borders of the ulcer, and shades off into a healthy 
membrane beyond. The site of these deep, tertiary ulcers, is, 



150 DISEASES OF THE FAUCES. 

in the order of their frequency, the tonsil, the soft palate and 
uvula, and the posterior wall of the lower- pharynx ; though 
in whatever locality they originate, their tendency is to extend 
to neighboring parts. When occurring in the pharynx, how- 
ever, their destructive progress is somewhat limited, that is, 
they manifest a tendency to extend only to the posterior pil- 
lars of the fauces laterally, to the oesophagus below, and to 
the pharyngeal tonsil above without involving it. This is an 
appearance not infrequently seen, though it must not be un- 
derstood that these ulcers do not at times extend from the 
pharynx to the pillars of the fauces and soft palate. Occur- 
ring in the soft palate, the}^ result very soon in perforation, and 
an abnormal opening into the posterior nares. 

The resulting cicatrices from the healing of these ulcers, as 
above stated, is marked by very extensive contractions which 
may result in serious deformities in the fauces. These contrac- 
tions or deformities are due partly to the cicatrization, partly 
to abnormal adhesions which are liable to take place, and 
parti 3^ to the destruction of tissue resulting from the morbid 
process. The most frequent deformity consists in tlie inter- 
ference with the proper function of the soft j^alate and uvula 
by their more or less complete destruction, or from their being 
drawn to one side or the other by the abnormal contractions. 
A not infrequent result of these ulcers is adhesion between the 
soft palate and pharynx, b}^ which the normal opening is more 
or less completely closed. I have in several cases seen so com- 
plete a closure of this orifice that the smallest probe was passed 
with difficult}". A perfect closure never occurs. 

Treatment. — The early recognition of these ulcers and their 
prompt and vigorous treatment is of the utmost importance, as 
oftentimes their destructive progress is so rapid as to result in 
serious loss of tissue in a comparatively short time. The treat- 
ment consists in the prompt administration of large doses of 
iodide of potash carried to the extent of saturation of the system. 
I generally commence with fifteen grains, given three times a day, 
and increase the dose three grains each day, until a marked 
change in the character of the ulcerative process is recognized. 
The use of mercury is of limited value in this manifestation of 
syphilis, and it should rarely be resorted to until the ulceration 
has entirely healed, when it should be administered, according 
to the rules which govern the management of any case of con- 



SYPHILIS OF THE PHAEYNX. 151 

stitutional syphilis. It is scarcely necessary to add that I co- 
incide with the teaching that the proper treatment of constitu- 
tional syphilis requires the administration of mercury for a 
period extending over from twelve to eighteen months. In 
connection with general treatment local measures are of the 
utmost importance. This consists in the thorough washing out 
and cleansing of the ulcerated surface by means of one of the 
cleansing solutions given in the appendix, and applied by the 
atomizer, or syringe. Great care should be exercised in thor- 
oughl37- removing all the debris and pus from the surface of the 
ulcer by this means. Following this, there should be applied 
over the whole of the diseased surface iodoform, either pure, or 
in connection with tannin and morphine, as given in the ap- 
pendix. The other remedies which have been resorted to in 
these cases, consist of destructive agents, as nitrate of silver, 
nitric acid, acid nitrate of mercury, chromic acid, caustic pot- 
ash, the actual cautery and galvano- cautery ^ What was said^ 
however, in regard to superficial ulcerations, as to the action of 
these remedies, holds true also in the main in regard to deep 
ulcers : that they add to the loss of tissue, they are extremely 
painful, and, as a rule, not so efiicient as iodoform. That cases 
may occur which do not readily and promptly yield to the com- 
bined action of the iodide of potash internally, and iodoform 
locally, may undoubtedly be true, and yet, in a rather excep- 
tionally large experience, I have never met with them. 

As regards the extensive deformities resulting from the cica- 
trices from these ulcers, they often produce conditions which 
become the source of no little discomfort or distress in their in- 
terference with the functions of the fauces. Especially is this 
true of those cases in which there has resulted almost complete 
closure of the naso-pharyngeal opening, giving rise to nasal 
stenosis, impairment of the voice, etc. It would seem that 
something might be accomplished in these conditions by opera- 
tive measures. It has been, I believe, the universal experience, 
that after cutting these adhesions, they close up immediately, 
and resist every effort to keep the parts separated. I have oc- 
casionally made the attempt to relieve them by dilatation, but 
with absolutely no success. It must be confessed then, that, 
at present, we possess no means of remedying these frequently 
distressing conditions, and that all that lies in our poWer is 
simply to palliate some of the more prominent symptoms. 



152 DISEASES OF THE FAUCES. 



Strumous Ulcekatiox of the Pharynx. 

It is still a somewhat unsettled question in regard to stru- 
mous ulceration in the fauces, whether it constitutes a sepa- 
rate and independent form of ulcerative action, or whether it 
is not realljT- a manifestation of congenital syphilis. There are 
many features of the disease which in a marked degree resem- 
' Me the syphilitic form of faucial ulceration, while others would 
seem to establish it as an independent disease. To finally set- 
tle the question, and fully establish the true status of so-called 
scrofulous ulcerations of mucous membranes, will require 
that the clinical investigation shall extend over a very length- 
ened period of time, and that it shall be somewhat more care- 
fully made than has heretofore been done. For the present 
I am disposed to regard the two diseases as distinct, while 
nevertheless accepting the view that there is most excellent 
ground for regarding them as identical. 

In strumous ulceration of the pharynx we have manifested 
a form of destructive ulceration which presents certain pecu- 
liar and distinctive characteristics. It generally commences in 
the soft palate or uvula, in a small localized inliltration of the 
membrane which soon undergoes disintegration, and develops 
into a true ulcerative j)rocess. This may occasionally have its 
starting-point in the tonsil or pillar of the fauces, but rarely, if 
ever, on the pharyngeal wall. It extends by an extremely slug- 
gish and indolent progress to the neighboring parts, and even- 
tually^ involves the whole fauces, including the hard palate, 
tonsils, pillars of the fauces, and wall of the pharynx. It may 
also extend to the nasal cavity and larj^nx. Its mode of ex- 
tension to the nasal cavity is, as a rule, by involving progres- 
sively the mucous membrane and j^eriosteum of the hard pal- 
ate, and finally attacking the bone, leading to necrosis and 
perforation, then gradually invading the nasal cavity to the 
destruction of the bony septum and other parts. 

The progress of this destructive j^rocess is marked by pe- 
riods of apparent improvement and even arrest of the ulcera- 
tive action ; but this is, as a rule, deceptive, and sooner or later 
the disease is re-established, not, however, with any renewed ac- 
tivity, but with the same indolent but slowly progressive action. 
Furthermore it is noticed that the apparently successful at- 



STEUMOUS ULCEEATION OF THE PHAEYISTX. 153 

tempts of nature to heal the ulcer are balked by the absence of 
an}^ attempt at genuine repair by the deposition of true granu- 
lation-tissue. The surface seems to become glazed over by a 
thin film which offers no valid resistance to the re-establish- 
ment of the disease. There is also a total absence of any at- 
tempt at cicatrization or contraction of the parts, as a rule. 
As the wasting process goes on, there is noticed frequently ab- 
normal adhesions between the soft palate and pharynx, or pil- 
lars of the fauces, which serve to seriously impair the function 
of deglutition. The gums and cheeks are sometimes involved 
in the diseased action, as well as the tongue, the ulcer present- 
ing the same appearances as in other parts. 

The gross appearance of the ulcerated surface is peculiar. 
The edges of the ulcer are raised above the surface and are 
well marked and distinct. They are rounded and cord-like in 
appearance, and of a slightly reddened color. The mucous 
membrane beyond is not congested, and there is an absence, as 
a rule, of anything like the areola of the syphilitic ulcer. The 
mucous membrane surrounding the ulcer, however, for a con- 
siderable distance, is somewhat thickened and presents a slight- 
ly nodular aspect. The surface of the ulcer is, in its general 
coloration, of a pale pink tinge,, and somewhat mottled in ap- 
pearance. It is covered with minute reddened points, or pap- 
pilated elevations, which give it a worm-eaten aspect. The 
discharge from the surface is not extensive in amount, and con- 
sists' of a thick, ropy, muco-pus, which adheres somewhat tena- 
ciously to the diseased surface. There are no enlarged blood- 
vessels noticeable beyond the border of the ulceration. 

The wasting process is an extremely slow one, and as re- 
marked there is no attempt at closure of the gaps made by the 
loss of tissue, the parts seeming to melt away, as it were, and 
disappear. 

Strumous ulceration is essentially a disease of infancy and 
childliood. It may malve its appearance at any time from birth 
to eight or ten years of age, but rarely later. The latest age at 
which I have met with it was in a boy of seventeen, but in this 
case tlie ulceration set in at eight years of age, and the prog- 
ress of the affection was marked repeatedly by tlie usual ap- 
parent arrest of the disease for a time, followed by its recur- 
rence, until it finally involved the nose, fauces, and larynx. 

The general condition of a patient suffering from this local 



154 DISEASES OF THE FAUCES. 

manifestation of struma, is of course familiar to all. He pre- 
sents, sooner or later, the usual pale, anaemic, putty-faced ap- 
pearance, with the loosely-hung, flabby, spongy skin, coarse 
features, swollen abdomen, enlarged cervical glands, and gen- 
erally badly nourished and emaciated condition, by which we 
recognize the scrofulous cachexia. 

The subjective s^anptoms which attend the affection are 
mainly those due to the character and extent of the morbid ac- 
tion. If the integrity of the soft palate is much encroached 
upon, deglutition is not only painful, but the articles of food are 
liable to make their way into the nasal cavity during the act. 
The voice assumes a shrill, piping character, as a rule, but this 
is generally due to the laryngeal cavity being involved. It 
loses its nasal character from the destruction of the soft palate 
and closure of the palato-pharyngeal orifice. There is more or 
less cough present of a harsh and irritating character. Pain is 
not, as a rule, a prominent symptom. Hearing may be impaired 
by the disease extending to the phar3^ngeal orifice of the Eusta- 
chian tube. 

Treatment. — As long as there is any doubt of the true 
nature of the disease, it becomes a question as to the propri- 
ety or justifiability of administering anti-syphilitic remedies, 
on the ground of its possible specific nature. I have made 
faithful and protracted trial of this treatment in several cases, 
in which I made the diagnosis of scrofulous ulceration, with 
the hope that my opinion might be discredited by the success 
of the remedies. The failure to accomplish any good results 
in these cases has, in part, led me to adopt the view that the 
disease is non-syphilitic. Of course it may be said that there 
is a strumous ulceration, and also an ulceration in the fauces 
of congenital syphilis. This is quite true, but in my experi- 
ence the congenital syphilis presents much the appearance of 
acq lired syphilis, but not that of the disease I have attempted 
to describe. 

In the management, therefore, of these cases, while it is 
justifiable to administer the anti-syphilitic remedies, I should 
certainly urge that they be given in connection with cod- 
liver oil and the iodide of iron, and such remedies as serve to 
control the strumous condition. In addition to this, local mea- 
sures should be resorted to for the control of the ulcerative 
action. These should consist in the frequent application of 



TUBERCULOSIS OF THE PHAEYISTX. 155 

iodoform after the parts have been thoroughly cleansed. The 
cleansing solution may be applied in the form of spray, or by 
the syringe, the solution used being the Dobell's solution (See 
Appendix, Prescription No. 1). In this form of ulceration the 
iodoform should be combined as follows : 

5 . Morphia sulpli gr. ij. 

Tannin 3 ss. 

Iodoform 3 iss. 

M. 

The application should be repeated two or three times each 
week. 

Much can be done by these local measures provided the 
general condition can be corrected. If the disease is not of 
long standing much may be hoped for as the result of treat- 
ment. • If, however, the disease has existed for several years, I 
think it is the experience of most observers that the hope of 
more than relief is somewhat problematical. 

Tuberculosis of the Pharte-x. 

This is a disease characterized by the development in the 
fauces of that form of ulcerative action which in the larynx is 
called tubercular laryngitis, or laryngeal phthisis. Without 
entering into a discussion, for the present, at least, of the true 
pathology of the disease, it is sufficient to say that what holds 
true in regard to the laryngeal disease is true also of the dis- 
ease occurring in the pharynx. More extended notice of its 
pathology will be found in the article on laryngeal phthisis. 

Perhaps a clearer conception can be obtained of this rare affec- 
tion by the relation of the following case. I was called on the 
2d of April, 1878, to Andover, N. J., to see in consultation with 
Dr. Jno. Miller, of that place, a case presenting the following 
liistory : Mrs. C. F. C, aged twenty-one. Her mother and sis- 
ter died of consumption, her father and brothers living, and in 
good liealth. She had always been well, and had never been 
subject to any cough, catarrh, or throat trouble. She lived in 
a farming district, and her home surroundings were everything 
that could be desired as conducing to good liealth. On Febru- 
ary 8th Dr. Miller had been called to see her, and found her 



166 DISEASES OF THE FAUCES. 

suffering from an attack of follicular pharyngitis, involving the 
soft palate and pillars of the fauces. There was deep submu- 
cous infiltration, the uvula being markedly enlarged. The fever 
was of a mild type, and pain very slight while the fauces were 
at rest, although deglutition was somewhat painful. She was 
able to be up, and assisted in the duties of the household. The 
doctor saw her but once in four or five days, and under treat- 
ment the disease gradually subsided, and by the 1st of March 
she was convalescent. On the evening of the 6th of March she 
was married, although at the time she was somewhat delicate, 
without being able to refer her symptoms to anything more than 
the slight discomfort which remained from the condition of the 
throat, and the somewhat slow convalescence from the follicular 
disease of the fauces. On the da}^ following her marriage she was 
seized with a chill, followed by high fever. On the 8tli Dr. Miller 
saw her again, and found her with a violent fever, high tempera- 
ture, and rapid pulse ; there was considerable pain referable to 
the fauces, deglutition was extremely painful, and there was a 
slight hacking cough. On inspection, the site of the original 
follicular inflammation of the fauces was found to have become 
the seat of apparently aphthous patches, extending over the 
soft palate and uvula and a portion of the wall of the 23harynx. 
There was extreme j)rostration, and the patient was confined to 
lier bed. Examination of the lungs failed to detect any morbid 
condition. From March 8th until A2:)ril 2d the above symp- 
toms continued, there was a considerable discharge of niuco- 
pus, and the cough became more irritating and ])ersistent, tiie 
fever remained high, pulse rapid, and weak. Liquid food was 
taken in fair quantities, but the swallowing of solid food be- 
came so painful as to be rarely attempted. The voice was not 
at any time markedly impaired. On the 2d of April, eight 
weeks after the first symptom of throat trouble was manifest, 
and four weeks after the graver form of the disease of the fauces 
had set in, I saw her. I found her in bed, apparently well nour- 
ished, and not much emaciated, but presenting that peculiar 
facies which showed her to be suffering from some marked dys- 
crasia. There was a peculiar grayish 23allor" about the face and 
lips, while at the same time there was a hectic spot on each 
cheek ; the skin was hot to the touch, and very dry ; the 
tongue coated and parched ; the breath hot, feverish, and 
rapid ; axillar}^ temperature, 105° ; pulse, 120. The examina- 



TUBERCULOSIS OF THE PHARYNX. 167 

tion of the lungs showed marked dulness, with broiicho-vesica- 
lar respiration in the right interscapular region ; there were no 
moist rales heard in any portion of the lung, and the physical 
signs otherwise were not noticeable. On examining the fauces, 
with the tongue depressed, I at first merely saw the parts show- 
ing a uniform pallor throughout the whole region, and covered 
with a thick, tenacious, ropy mucus ; but on the second and 
closer inspection I discovered that there was ulcerative action 
going on and involving the whole posterior wall of the pha- 
rynx, the soft palate and uvula on the right side, and extending 
to the hard palate, the palatine arch, and a portion of the soft 
palate on the left side. On the right side the palate was de- 
stroyed as far as the giosso-palatine arch, but so evenly and 
smoothly as almost to escape notice save from the lack of sym- 
metr}'- on the two sides. Examination of the larynx showed 
that the epiglottis, the ary-epigiottic folds, the arytenoid car- 
tilages and commissure were thickened and involved in that 
peculiar form of ulcerative action which we all recognize as ad- 
vanced laryngeal phthisis, the ulceration involving the false 
cords while the true cords were intact. The ulceration in the 
pharynx was peculiar and characteristic, and was unquestion- 
ably the same as that which, when occurring in the larynx, is 
called tubercular laryngitis, or laryngeal phthisis. The closest 
examination and comparison of the laryngeal and pharyngeal 
disease failed to show any difference whatever in the gross 
a]opearances ; there was a superficial waste or destructive pro- 
cess going on, and at the same time there was almost total ab- 
sence of any evidence of granulation-tissue, or attempt at re- 
pair. There was no well-marked line of demarcation ; there 
was no depression of the edges, the depression of the ulcerated 
surface sloping off, as it were, toward its border, which was 
somewhat ragged and irregular ; and there was no areola of in- 
fiatned membrane beyond the ulceration. Its surface was of a 
grayish color, but so also was that of the mucous membrane of 
the whole fauces, and the general coloration was not markedly 
different in the healthy and diseased portions. The diseased 
surface was coated with a slimy, ropy mucus which is peculiar 
to phthisical ulceration ; we generally speak of it as muco-pus, 
but the pus-cells, however, are probably comparatively few in 
number, and it is mainly composed of mucus and the debris of 
the wasting process, covering and adhering to the ulceration, and 



158 DISEASES OF THE FAUCES. 

partially concealing or masking it. It is detached and voided 
with considerable difficulty. 

Fraenkel likens the surface of a phthisical ulceration to cut 
bacon ; Laboulbene to the track of an earth worm in moist 
sand ; it is difficult to describe it, but when once seen it is un- 
mistakable. The subsequent history of the case was simply 
that of futile attempts to arrest the disease, and partially suc- 
cessful attempts to relieve. She died on April 15tli, the high 
temperature persisting to the last, rarely being reduced below 
103°, though quinine was given freely. 

This young lady, while in apparent good health, caught 
cold, which resulted in an attack of acute follicular inflamma- 
tion of the mucous membrane of the soft palate ; under simple 
remedies the attack was subsiding, when there was suddenly 
manifested the fatal diathesis, which had carried off her mother 
and two sisters, and which was a perpetual menace to her, 
during her whole life, viz., the tubercular diathesis. Under 
its influence the inflamed follicles which were undergoing reso- 
lution, now- took on ulcerative action, and the typical waste 
set in which characterizes the disease. There was now mani- 
fested a very grave, general condition, and yet there was no 
local manifestation of this more than an ulcerative process, of 
moderate extent, in the fauces. The general febrile motion 
and its accompanying symptoms indicated something more 
than a mere local disease ; it was a systemic condition which 
arrested the progress of resolution which was going on, and 
destroyed the lyls meclicatrix naturce, and so far dominated 
the reparative processes, as to utterly change their character 
and substitute in their place a destructive process. The local 
disease and the blood condition progressing, the patient finally 
succumbs, and dies with exhaustion from acute miliary tuber- 
culosis. 

We may generalize as follows : during the course of a 
general or pulmonary tuberculosis, but more frequently as a 
primary manifestation of a general dyscrasia or diathesis, there 
sets in upon the pharynx, soft palate, or neighboring parts, an 
ulcerative process presenting the appearances described, in the 
case above presented, and which we called phthisical or tu- 
bercular ulceration. There is severe pain always, and often 
of a most acute and lancinating character. The discharge is 
not purulent, but a dirty, grayish muco-pus. There is, as a 



TUBERCULOSIS OF THE PHAEYNX. 



159 



rule, high fever from the onset, the temperature ranging from 
103° to 106° ; this is a persistent and continued fever, not con- 
trollable by quinine. The tendency of the ulceration is to 
extend laterally and also very soon to the larynx; for I find 
no report of any case in which laryngeal disease has extended 
to the pharynx. The course of the disease is rapid ; this Is 
especially the case if the pharyngeal ulceration is primary. 
In this case death ensued from exhaustion in from six to 
eight weeks. If the pharyngeal disease is secondary to pul- 
monary tuberculosis, the fatal termination may be postponed 
from four to six months or even longer. The diagnosis is quite 
simple to one familiar with the laryngoscopic appearances in 
laryngeal phthisis in the ulcerative stage, yet so careful an 
observer as Fraenkel made the mistake of placing patients 
suffering from this disease under anti-syphilitic treatment ; 
not only failing to benefit them, thereby, but on the contrary, 
doing them absolute harm. 

The only other affection with which it may be confounded 
is strumous ulceration. Grrouping the prominent characteris- 
tics of the three forms of ulcerative action, we will find that 
they present marked differences. 



Deeply excavated. 

Deep red, angry-looking 

areola. 
Sharp cut edges. 

Well marked line of demar- 
cation. 
Yellow purulent discharge. 

Profuse discharge. 
Rapidly destructive. 

Erodes deeply. 

No general dyscrasia. 

No fever. 



Phthisis. 

No apparent excavation. 
No areola. 

Somewhat irregular, not 
sharp cut. 

Line of demarcation not 
distinct. 

Grayish, semi-opaque, ropy 
mucous discharge. 

Slight discharge. 

Moderately active destruc- 
tion. 

Extends laterally and super- 
ficially. 

Marked general dyscrasia. 

High fever. 



. Scrofula. 

No excavation. 
No areola. 

Everted and raised edges. 

Line of demarcation well 

shown. 
Muco -purulent discharge. 

Slight discharge. 

Very slowly destructive. 

Very slowly and in all di- 
rections. 

Strumous habit well 
marked. 

No fever. 



Treatment. — From wliat has been said it will be inferred 
that treatment is of little avail. Our effort will be mainly 
to correct, as far as possible, the general habit, to alleviate 



160 DISEASES OF THE FAUCES. 

symptoms, and to control, if possible, the extension of the 
ulcerative process. 

In carrying out the first indication the same rules should 
be followed as govern the management of a case of pulmonary 
consumption. To relieve pain and cough, anodynes should be 
administered quite freely. To control the iilcerative action, 
and thus to alleviate the more distressing features of the 
disease, it is probable if treatment is commenced sufficiently 
earl}^, that much may be done, by topical applications. The 
first indication is to thoroughly cleanse the ulcerated surface 
ot its adherent mucus, by the use of some mild alkaline solu- 
tion, such as a solution of borax, bicarbonate of soda, or bi- 
carbonate of potassa, gr. v.-x., in an ounce of water. To this 
there may be added, with benefit, carbolic acid, gr. J.-iij. to 3 j. 
This should be applied by means of an atomizer. A syringe, 
probang, or even the camel' s-liair brush, being not only irritat- 
ing, but also failing to thoroughly cleanse. After the parts are 
cleansed, there should be applied iodoform as the most certain 
and efficient of all our remedies in controlling all forms of 
ulcerative action. The iodoform ma}^ be applied pure or light- 
ened by the addition of powdered starch or lycoj^odium. There 
should also be added morphia, gr. ij.-3j., for its local seda- 
tive effect. 

An efficient combination will be found as follows : 

5 . Morplii;© sulph gr. vi. 

lodoformi 3 ij. 

Pulv. amyli 3 j. 

M. 

This should be thoroughly triturated so as to form a fine, 
smooth powder. 

In making the application, the powder blower shown in 
Fig. 47 should be preferred ; as in this manner a thin, even film 
may be deposited on the diseased surface, and the irritation 
avoided which would be caused by piling too much of the 
remedy on the parts. In the absence of the insufflator, a quill 
or glass tube may be used, a very small quantity of the powder 
only being blown on at a time. Caustics or any irritating appli- 
cations are to be avoided, as not only failing to do good, but as 
adding greatl}^ to the suffering of the patient. 



TUBEECULOSIS OF THE PHAEYNX. 161 

The food and drink must l?e selected with recognition of 
the fact that they pass over and come in contact with the dis- 
eased surface, and hence should be as bland and unirritating 
as possible. Counter-irritation is of very doubtful benefit, and 
undoubtedly adds to the discomfort of the sufferer. Steam in- 
halations are not only of no service, but they are liable to do 
mischief in promoting relaxation of the parts and increasing 
the discharge. 

11 



CHAPTER X. 

KEUKOSES OF THE PHARYNX. 

Herpes of the Pharynx, or Herpetic Sore Throat. 

This is an extremely rare affection compared with the fre- 
quency with which herpetic eruptions are met with on the exter- 
nal surface of the body, and yet that we do meet with a genu- 
ine herpes in the fauces is unquestionable. It consists in the 
development in the mucous membrane of an eruption present- 
ing all the appearances of true herpes, and attended with cer- 
tain symptoms, both local and constitutional, which render it 
analogous to herpetic eruptions on the skin. I have met with 
half a dozen cases of this affection in a somewhat exception- 
ally large experience in throat diseases, which leads me to 
regard it as a rarer aff'ection than is usually supposed. In 
three of the cases which I have seen, the eruption sliowed itself 
in the form of herpes iris, that is, there was developed in the 
mucous membrane small rings of minute papules, partially or 
completely enclosing a tract of healthy membrane. In one 
case that I met with, the small papules seemed to arrange 
themselves somewhat irregularly in the mucous membrane of 
one side of the fauces ; in another case they seemed to form a 
line along the junction of the hard and soft palate. These 
papules manifested no tendency to the complete formation of 
vesicles ; but consisted in minute red j)oints in which the mem- 
brane was raised above the surface very slightly, and seemed 
somewhat pointed or acuminated. 

As to what especial condition gave rise to the eruption I am 
somewhat uncertain, but am disposed to regard it as a local- 
ized inflammation of the papillae of the sub-epithelial layer of 
the mucous membrane, originating probably in the terminal 
filaments of the nerves. In those cases in which it took the 
form of herpes iris, the rings were somewhat irregular in out- 



HERPES OF THE PHARYNX. 163 

line ; not perfectly continuous, yet approximating sufficiently 
to an iris-like ring to warrant the name of herpes iris. The 
eruption in all the cases that I have seen has been on the soft 
palate and uvula ; and, furthermore, it has always been con- 
fined to one side. The eruption was not a continuous one ; 
but the patches would make their appearance, and after a 
course of from five to ten days, would disappear, and recur 
again after an interval of perhaps, a week, or even longer, 
sometimes remaining absent for months. The same was true of 
the individual points of eruption ; they showed a tendency to 
come and go inde23endently of their fellows. The prominent 
symptoms to which they give rise are more or less pain, refer- 
able to the faucial region, constant and annoying in character, 
with pain in swallowing, and a general sense of discomfort 
about the throat, attended, oftentimes with a most intolerable 
sense of itching. The appearances are such as already no- 
ticed. Minute spots and papules, stand out prominently as 
to color, showing a deep purplish red, in contrast with the 
healthy mucous membrane surrounding them, always on one 
side of the throat, and scattered irregularly, or arranging them- 
selves in the form of rings, as in herpes iris. 

Treatment. — I am disposed to believe the affection is a con- 
stitutional one, and that its successful management depends 
on the internal administration of remedies. Tiie patients 
usually present decided evidences of the nervous tempera- 
ment. They are subject to neuralgias, or, possibly, hysteri- 
cal symptoms, and present all the evidences in appearance and 
history which go to make up what we call the nervous disposi- 
tion. They are also liable to show evidences of impaired gen- 
eral health. They are anaemic or chlorotic, and hence require 
decided tonic remedies. 

The plan of treatment which I have pursued has been the 
administration of cod-liver oil, barks, and iron, in connection 
with arsenic. This should be given for a considerable length 
of time, certainly until the general health has been fully re- 
stored, the object being kept in view of relieving from the im- 
mediate attack, and of preventing any recurrence of the affec- 
tion. In addition to the general treatment, certain local 
remedies may be used in order to give relief to the pain and 
intolerable itching to which the affection gives rise. For this 
purpose I have usually found the best relief from a gargle of 



164 DISEASES OF THE FAUCES. 

carbolic acid, ten grains to tlie ounce, or even stronger, if neces- 
sary. This remedy, as we know, acts as a local sedative in 
addition to its other properties, and it is this effect that is ob- 
tained by its use in herpetic sore throat. 



Hysteeo-Neueoses of THE Fauces. 

A degree of prominence has been given of late j^ears to the 
existence of certain reflex nervous symptoms referable to the 
upper air-passages, but dependent on morbid conditions of the 
uterus and its appendages. Valuable contributions, recording 
a number of careful clinical observations, have been made on 
the subject by Echeverria, Holden, Englemann, Cutter, and 
others, which serve to establish the fact of a close intimacy 
between the two parts, and that a morbid condition of the 
pelvic organ or its apj^endages, may give rise to more or less 
distressing symptoms referable entirely to the fauces. More- 
over, a close examination of the air-passages fails to detect any 
morbid condition, and faithful topical medication fails to af- 
ford any relief to the sj^mptoms complained of. 

The symptoms, as a rule, are not such as would be caused by 
an organic or structural change in the part, but rather such 
as might be of a purely neurotic origin. The voice is not af- 
fected, there is no excess of the normal secretion of the part, 
nor is there any impairment of function. There is usually a 
cough present, but it is of a dry, irritative character ; a more 
or less constant hacking. The lorominent symptom, however, 
as a rule, is pain. This is never of a lancinating character, but 
is rather a dull aching, referable to the pharynx and pillars of 
the fauces, and often extending to the angle of the Jaws. It 
also varies very much with the feelings of the patient, being 
aggravated as the result of fatigue or w^eakness from any cause. 
Occasionally these symptoms are aggravated by the approach 
or onset of the menstrual flow. In the majority of cases, how- 
ever, this symptom is not jDresent. 

If the symptoms are referred to the larj^nx, the cough be- 
comes prominent, assuming a stridulous and oftentimes spas- 
modic character, the voice being still unimpaired. 

The bronchi also occasionally become the seat of reflex neu- 
rotic symptoms, in which case there occurs a spasmodic cough, 



HYSTEEO-NEUEOSES OF THE FAUCES. * 165 

attended with marked dyspncEa. These attacks generally oc- 
cur at night, and are attended with all the symptoms of genuine 
spasmodic asthma. 

The uterine conditions which may give rise to these reflex 
symptoms embrace flexions, displacements, ulceration and in- 
flammatory affection of the uterus, and also inflammation and 
displacement of the ovaries. In short, it may be stated that 
clinical observation demonstrates the existence of such an in- 
timate sympathy between the throat and pelvic organs, that 
any morbid condition occurring in the latter may give rise to 
certain symptoms which the sufferer refers entirely to the 
upper air-passages, and in which the manifested and observed 
symptoms also belong to these parts. And, furthermore, that 
while measures directed to the air-passages are totally unavail- 
ing to give relief, the recognition and proper treatment of the 
morbid condition of the uterine organ serves to afford entire 
relief to the respiratory symptoms. An inspection of the 
throat, of course, in this affection, is entirely negative, and fails 
to reveal any morbid condition. And, moreover, there is no 
method by which, from an examination of the throat, we can 
recognize the fact that sj^mptoms referred to that part are due 
to a diseased condition in the pelvic organs. It simply remains 
therefore for us, in cases such as described, when a laryngo- 
scopic examination fails to reveal the cause of the symjDtoms, 
to bear in mind this possible other source for them. This fur- 
ther investigation discovering the true cause of the troublesome 
symptoms, the indications for treatment are clear ; the uterine 
disease must be treated. 

The age of the patients in whom these neuroses are liable to 
occur is from fifteen to forty-five, that is during menstrual life. 
They occur also alike among married and unmarried women. 
These patients, moreover, are not necessarily of a hysterical 
character, although, as a rule, they possess something of a 
nervous temperament. 



DISEASES OF THE NASAL CAVITY. 



CHAPTER XL 



CATAKKHAL AFFECTIONS OF THE NOSE. 



Anatomy.— The nasal cavities are two wedge-shaped cavi- 
ties extending from the nostrils, in front, to the posterior nares, 
two oval-shaped openings, by which they communicate with the 
pharynx. The roof of these cavities is narrow and somewhat 

arched, and is formed 
by the nasal, the eth- 
moid, and the sphenoid 
bones. The Hoor is 
formed by the palatine 
processes of the supe- 
rior maxillary and pal- 
ate bones. They are sep- 
arated from each other 
in the median line by 
tlie septum, which pro- 
vides a smooth inner 
wall to each cavity, 
and is formed by the 
perpendicular plate of 
the ethmoid and the vo- 
mer posteriorly, and by 
the cartilaginous sep- 
tum anteriorly. The outer wall of each cavity is formed by 
the superior maxillary and palate bones, and is traversed an- 
tero-posteriorly by three scroll-shaped bones, the turbinated, 
which serve to markedly increase the surface over which the 




Fig. 86.— Outer wall of the left nasal cavity: 1, frontal 
bone ; 2, nasal bone ; 3. superior maxilla • 4, body of the sphe- 
noid ; 5, superior, 6, middle, and 7, inferior turbinated bones ; 
8, orifice of the Eustachian tube. 



ANATOMY OF THE NOSE. 



167 



mucous 'membrane lining the cavity is displayed, and also to 
divide eacli fossa into three incomplete passages, the superior, 
middle, and inferior meatuses. This is well illustrated in Fig. 
86, which shows the outer wall of the left nasal fossa. The 
transverse section shown in Fig. 87 still further illustrates the 
conformation of these cavities with the arrangement of the tur- 
binated bones. 

In this connection reference should be made to the acces- 
sory cavities which communicate with the nasal fossae, and 
which are oftentimes involved in morbid processes which have 
their origin in the nasal cavities. 

The antrum of Hlglimore (Fig. 87, 9), the largest of these 
accessory cavities, is a triangular-shaped cavity, hollowed out 
in the body of the su- 
perior maxilla. Its 
roof is formed by the 
floor of the orbit, and 
its inner boundary is 
formed by the outer 
wall of the nasal cavi- 
ty. It communicates 
with the nares by an 
irregular shaped open- 
ing into the middle 
meatus. 

The frontal sinuses 
(Fig. 86, 1) are two ir- 
regular cavities which 
lie between the two 
tables of the frontal 
bone. They are absent 
in childhood, but become developed in adult life. They com- 
municate with the nares by the infundibulum, a rounded canal 
which opens into the middle meatus. 

The sphenoidal sinuses (Fig. 86, 4) are two cavities hol- 
lowed out in the body of the sphenoid bone, and separated 
from each other by a thin lamella of bone. They communicate 
with the nares by small openings in the superior meatus. 

The lachrymal duct enters the nasal cavity by a small 
opening in the inferior meatus, beneath and somewhat covered 
by the overhanging inferior turbinated bone. 




Fig. 87. — Transverse section of the nasal cavities seen from 
behind : 1, frontal bone ; 2,' crista galh ; 3, perpendicular plate 
of the ethmoid ; 4 — 1, ethmoid cells ; 5, middle, and 6, lower tur- 
binated bones ; 7, vomer ; 8, malar bone ; 9, antrum of High- 
more, and 10, its opening into the middle meatus. 



168 



DISEASES OF THE NASAL CAVITY. 



The mucous membrane lining tlie nose is continuous with 
that of the pliarynx, and extends into the Eustachian tubes and 
the accessory cavities. Its superficial layer is composed of tes- 
selated epithelium in the upper portion of the cavities, as low 
as the middle turbinated bone and the upper third of the sep- 
tum. The remaining portion of the lining membrane is en- 
dowed with columnar ciliated epithelium. This fact becomes 
of some importance in connection with those diseases of the 
cavity which act to destroy or impair the vibrator}^ motion 
of the cilige, as this function undoubtedl}^ has an influence in 
promoting the movement of mucus and facilitating its dis- 
charge ; hence, therefore, its abolition increases the tendency 
to an accumulation of the discharges in diseased conditions. 

This lining membrane jDOSsesses a considerable degree of 
thickness, which has the effect to reduce materially the size 
of the cavities ; especially is this thickness of the membrane 

noticeable over the convexity 
and under surface of the turbi- 
nated bones, more markedly the 
lower and middle. This is due 
largelj^ to the rich distribution 
of follicular glands with which 
the membrane of the nose is en- 
dowed, and which group them- 
selves to an extent in these locali- 
ties. In addition to this there is 
found in the deep layer of the 
membrane, over the convexity of 
the turbinated bones, a plexus of 
blood-vessels which is so rich in 
its distribution as to give to the 
part something of the character 
of an erectile tissue. 

The nerve supply (see Fig. 88) 
is derived from the olfactory, the 
Vidian, the naso-palatine, the nasal branch of the ophthalmic, 
and the anterior dental branch of the superior maxillar3^ 

The olfactory nerve supplies the nasal cavity with the special 
sense of smell. It pierces the cribriform plate of the ethmoid 
bone bj^ from fifteen to eighteen branches on each side, which 
are distributed to the membrane covering the superior and 




J 



■^^ 



i 



Fig. 88.— Nerves of the outer wall of the 
nasal cavity. (Hirschfeld). 1. network of the 
olfactory nerve : 2. branch of the nasal nerve ; 
3, spheno-palatine ganglion : 4, anterior pala- 
tine nerve, supplying the hard palate : 7, 8. 9, 
branches of the spheno-palatine ganglion, dis- 
tributed to the middle and upper turbinated 
bones : 10, Vidian nerve. 



PHYSIOLOGY OF THE NOSE. 



169 




middle turbinated bones and the upper third of the septum, 
terminating in minute, thread-like filaments which pass to the 
surface of the membrane between the epithelial cells (see 
Fig. 89). That portion of the nasal cavities to which the olfac- 
tory nerve is distributed is called the olfactory 
tract, while the lower portion, including the 
middle and inferior meatuses, is called the res- 
piratory tract. The entrance to the nose ante- 
riorly is guarded by a number of stiff hairs or 
vibrissse, whose object is to prevent the entrance 
of particles of dust or other impurities in the in- 
spired air. 

■PHYSI0L0GY^ — The nose has a threefold func- 
tion to perform in the economy. It is the organ 
which presides over the sense of smell ; it has a 
special duty to perform in respiration ; and it 
gives a certain character and resonance to the 
voice. 

TJie sense of smell. — Minute particles of odor- 
ous bodies, floating in the atmosphere, are drawn 
into the nasal cavity with the act of inspiration, 
where, being arrested, and lodging against the 
moist membrane of the olfactory tract, they are 
dissolved in its mucus, and in this state of solu- 
tion, coming in contact with the terminal fila- 
ments of the olfactory nerve, their peculiar quali- 
ties are recognized and appreciated. The proper 
enjoyment of this function requires that the mem- 
brane shall be in a moist condition, that it shall 
not be clogged by any accumulation of unhealthy mucus or 
other matters, and that the nasal cavity shall be freely open, 
and not occluded by tumors or other morbid conditions, but 
that the ins^^ired air shall have free access to the olfactory 
membrane ; and, furthermore, that the olfactory nerve shall be 
in a healthy condition. 

Respiration. — The nasal cavities form an important part of 
the upper respiratory passages, it being the design of nature 
that respiration shall be carried on through them rather than 
through the mouth. In breathing through the nose the in- 
spired air becomes warmed by the blood- warm walls of the 
longer and more tortuous passage through which it makes its 



Fig. 89.— Meth- 
od by which the 
thread-like termi- 
nal fibres of the ol- 
factory nerve make 
their way to the sur- 
face of the mucous 
membrane, between 
the epithelial cells : 
n, epithelial cell ; 
6, olfactory cell ; c, 
the terminal thread- 
like fibre ; e, the ex- 
tremity of the fibre, 
comi50sed of minute 
hair-hke filaments. 



170 DISEASES OF THE NASAL CAVITY. • 

way to the lungs ; it becomes charged with moisture absorbed 
from the lining of the tract which it traverses ; and it becomes 
purified, in that the particles of dust and other matters which 
it may contain, are arrested by the vibrissse which stand guard 
over the entrance to the nostril, and also by the moist surfaces 
against whicli they impinge, and to which they adhere. In 
breathing through the mouth, on the other hand, the inspired 
air reaches the lungs in a cooler, drier, and less pure condi- 
tion, and hence one in which it is more irritating to the deli- 
cate structures of that organ. 

The xoice. — The function of the nasal cavity in modifying 
the voice is one of some importance, and consists simply in 
acting as a resonant chamber as it were. The voice is formed 
by vibrations of a column of air set in play by the movements 
of the vocal cords ; its pitch being regulated by their tension ; 
its volume being dependent on the force with whicli the cur- 
rent of air is driven through the rima glottidis, and hence, of 
course, by the lateral reach of each cord in a single vibration. 
The character of the voice, on the other hand, or the tone by 
which eacli voice is given its individualit}^, is dependent largely 
on the nasal cavity, the pharynx, and tlie mouth. The larynx 
simply forms the voice, articulate language being constructed 
out of the vocal waves by the movements of the soft palate, 
tongue, lips, etc. 

In uttering certain sounds, the soft palate is raised against 
the wall of the pharynx, and the nasal cavity is more or less 
completely shut off. This occurs in the utterance of a, /, o, 
etc. In the utterance of other sounds the palate is relaxed, 
and the air in the nasal cavity, as well as that in the mouth, is 
thrown into vibration, giving a nasal twang to the voice ; this 
occurs in uttering n, m^ etc. A good voice is dependent on 
the proper use of both the nasal and oral vibrations, and there- 
fore requires that the nasal cavity shall be free from obstruc- 
tion (by tumors, hypertrophy of its lining membrane, etc.), and 
that the movements of the soft palate shall not be interfered 
with. 

Anatomically, the nasal cavities are defined as extending 
from the nostrils to the posterior nares which open into the 
pharynx. Pathologically, however, we find that catarrhal dis- 
eases, both acute and chronic, involve not only the nasal cavi- 
ties proper, but also the vault of the pharynx ; hence, in treat- 



PHYSIOLOGY OF THE NOSE. 171 

ing of those affections wliicli are embraced under the general 
head of catarrhal inflammations in the nasal cavities, it should 
be understood that the parts involved in the morbid process 
include also the vault of the pharynx. 

* If we glance at a sectional diagram of the head, it will be 
seen that the border of the soft palate marks the boundary line 
between two avenues of the upper air-passages which are to- 
tally distinct and separate, both as regards their function and 
the influence of their surroundings. In that portion below the 
border of the palate we have a region which is being constantly 
impinged upon and swept b\^ the passage of food and drink, 
the result of which is necessarily that an accumulation of mu- 
cus is prevented, the surface of the membrane is kept compara- 
tively clean, and the mouths of the follicles are kept open. On 
the other hand, we And that the region which is above the bor- 
der of the soft palate is subjected to entirely different influen- 
ces. It is traversed by the current of air in respiration, and 
virtually nothing m^ore. It of course is endowed with certain 
functions in phonation, and is also the organ of the sense of 
smell ; but in this respect, for the present, it does not concern 
us. It is lined with a mucous membrane richly endowed with 
glands, and there is constantly going on a secretion of mucus, 
together with an evolution of epithelium in the process of 
growth. Nature has provided but one method by which this 
accumulation is gotten rid of ; the epithelial cells are endowed 
with cilicB, by which the mucus and worn-out epithelium are 
carried toward the outlets of the passage. 

The essential difference between the two regions, therefore, 
lies in the fact that the lower pharynx is constantly traversed 
and impinged upon by solids and fluids, while the upper pas- 
sage is only traversed by the current of air in respiration. 
Hence the lower region is kept comparatively clear of accumu- 
lations, while in the upper region the mucus secreted and the 
worn-out epithelium tend to accumulate in the sinuous passa- 
ges, and remain in contact with its lining membrane. Espe- 
cially is this true if, as the result of chronic inflammation, the 
cilice with which the epithelial coat of the membrane is endowed 
be destroyed. As the result, therefore, of this marked differ- 
ence of function and environment, it seems to me a fair conclu- 
sion that the true boundary line between these two regions 
should be drawn at the border of the palate. The point, there- 



172 DISEASES OF THE NASAL CAVITY. 

fore, which I would make is, that whatever the anatomical 
division may be, the true nasal cavity is the one I have de- 
scribed, and extends from the nostril to the border of the soft 
palate, and includes what we usually call the vault of the 
pharynx. This division is justified by the physiological di- 
vision of the parts, as I have said ; furthermore, and more 
prominently still, it is the division which, from a pathological 
point of view, must be made. 

The Vault of the Pharynx. — Regarding the pharyngeal 
vault as belonging, in a pathological point of view, to the nasal 
cavity, a brief reference to its anatomy is here given. The 



1^^ 




Fis. 90.— View of the vault of the pharynx with the fissured appearance of its glandular tissue. After) 
Iiuschka.) 1, pterj'goid process ; 2, vomer ; 3, posterior portion of tne roof of the nasal cavity ; 4, orifice 
of the Eustachian tube ; 5, mouth of the pharyngeal bursa ; 6, fossa of Rosenmiiller ; 7, irregularly 
fissured surface of the glandular tissue "which lifts up the mucous membrane into a number of low 
elevations. (Ziemosen. ) 



main interest which attaches to this region lies in the fact 
that we find displayed there a large aggregation of follicles 
and glands, which is so extensive, that it is usually spoken of 
as the "pharyngeal tonsil." In structure and function it is 
closely allied to the faucial tonsil, its minute anatomy being 
the same as the latter organ, with the only difference that 
It is not enclosed in a separate investing membrane. These 
glands seem to arrange themselves in elongated masses or 
ridges, sejDarated by deep fissures, whose general direction is 
from above downward. In the lower portion of the pharyn- 



ACUTE COEYZA, OE COLD IIN" THE HEAD. 



173 




geal tonsil there is often seen a small rounded orifice wliich. 
marks the outlet of a small flask-like pouch, 
the pharyngeal bursa. This orifice is not 
always well marked, but I have repeatedly 
observed it in the living subject. The mass 
is bounded laterally by the fossae of Rosen- 
miiller, and above it terminates somewhat 
abruptly in a transverse fissure, beyond 
which the mucous membrane is smooth and 
closely attached to the parts beneath. The 
lower boundary shades off gradually into 
the smooth membrane of the lower pharynx, 
the ridges disappearing, the masses becom- 
ing smaller, until there is noticed only the 
few scattered, rounded follicles seen by di- 
rect inspection below the border of the soft 
palate. 

This pharyngeal tonsil is not well marked 
in all cases, and in many it is so slightly de- 
veloped as scarcely to be noticeable. In 
these cases there is seen simply the rounded, 
dome-like cavity of the vault, lined with a 
smooth, unbroken mucous membrane. In 
Fig. 90 there is shown the condition ordi- 
narily observed when this organ is fairly well 
developed. Between this condition and one 
in which the pharyngeal tonsil is wanting 
we meet with it in all degrees of develop- 
ment. In Fig. 91 there is shown a section of 
the pharyngeal vault which has been drawn somewhat larger 
than the normal size. 




Fig. 91.— Antero-poste- 
rior section of the glandu- 
lar structure of the vault of 
the pharynx, somewhatlar- 
ger than normal. (Lusch- 
ka.) 



Acute Coryza, or Ordinary Cold in the Head. 



Tills is an acute infiammation of the mucous membrane lin- 
ing the nasal cavities ^^roper, and not infrequently extending 
to the pharynx and the accessory cavities, as the frontal sinus, 
the sphenoidal sinus, the antrum of Highmore, and also the 
lachrymal duct. In the large majority of cases it is caused by 
exposure to cold, though it is occasionally due to the inliala- 



174 DISEASES OF THE NASAL CAVITY. 

tion of acrid vapors or other irritants. In rare cases it occurs 
in those possessing idiosyncrasies by which a coryza is induced 
by the inhalation, in one case of particles of ipecacuanha, in 
another b}^ iodine, etc. It also occurs at the onset of certain 
of the exanthems, as measles, etc. That exposure to cold 
should result in a coryza so much more frequentl}^ than any 
other affection is probably due to the fact that the nasal mem- 
brane, on account of its exposed situation, is the site of a mild 
chronic inllammation in many cases when it is not suspected 
by the individual, giving rise as it does to scarcely any notice- 
able symptoms, more than this disposition to take cold easily. 

The attack is not usuall}^ ushered in by a chill, but rather 
by chilly sensations, with a feeling of lassitude and general 
malaise, followed by a mild febrile motion, with pains in the 
muscles and loss of appetite. Following this there is soon ex- 
perienced a sense of burning or prickling in the nose, a feeling 
of dryness and heat, which may last a few hours or more, when 
there sets in a watery discharge of a somewhat acrid character, 
which gradually changes to a mucous discharge more or less 
copious in amount, and this in time yields to a free discharge 
of a purulent character. The duration of the attack varies 
from three days to a week, and undergoes apparently complete 
resolution, although undoubtedly, if no measures are adopted 
for the control or limitation of the inflammatory process, there 
is left behind a condition which invites renewed attacks from 
a slighter exciting cause. 

The dr^aiess of the membrane which characterizes the onset 
of the attack is coincident with the stage of congestion and 
arrest of secretion which marks the commencement of any 
acute inllammation of a mucous membrane. Following this 
there occurs a free transudation of liquor sanguinis from the 
engorged blood-vessels, which supplies the serous discharge 
which constitutes the main portion of the earliest secretion 
which is poured out. The normal glandular structures of the 
membrane are soon stimulated into an excessive and morbid 
activity, and a profuse discharge sets in, consisting of mucus 
and epithelial elements, with an admixture of leucocytes, and 
a few red blood-corpuscles. As the disease progresses the se- 
cretion becomes overcharged with young cells, which are gen- 
erated with an increased activity, and assumes a purulent char- 
acter. 



ACUTE COEYZA, OR COLD IN THE HEAD. 175 

If the nasal cavities proper are alone aifected, the symptoms 
are mainly confined to the sense of discomfort referable to the 
nose, the increased secretion, the sense of fulness, or the com- 
plete occlusion, due to the swelling of the membrane, and the 
frequent and often distressing attacks of sneezing. 

If the frontal sinuses are involved, there is often a severe 
frontal headache ; if the tear-duct is involved, there is an over- 
flow of tears, with marked irritation of the conjunctiva ; if the 
disease extends to the antrum of Highmore, there is neuralgic 
pain referable to that region ; if the Eustachian tube is in- 
volved, there is ringing in the ears, with impaired hearing. 
The sense of smell is generally lost for the time, and thereby 
also the sense of taste is impaired. The integument about the 
margins of the nostrils is often inflamed as the result* of the 
irritating qualities of the discharge, which contains largely of 
saline matter. This is aggravated somewhat by the frequent 
use of the handkerchief, to which the sufferer is compelled to 
resort. 

Prophylaxis. — Those who are especially liable to take cold 
should, of course, exercise an additional carefulness in the 
avoidance of those causes which experience teaches them may 
give rise to an attack of acute coryza ; and yet an excessive zeal 
in this direction is to be avoided, since that over-carefulness 
for one' s health, which results in muffling the head and neck 
with too much covering, leads to an over-sensitiveness of the 
parts, by which the liability to take cold is much increased. 
It is not well, as a rule, to wear thick wraps about the neck, 
unless it becomes necessary as a matter of comfort. Exposure 
to a cold temperature alone is not sufficient to produce a coryza ; 
it is a draught of damp and chilly air which produces the mis- 
chief. This acts with a greater certainty of causing evil if the 
body is quiet and at rest. 

The daily use of a cold douche over the neck and shoulders, 
or sponging with cold water, is a measure of great value in pre- 
venting attacks of cold in the head. This not only acts to 
keep the emunctory function of the skin in a healthy state of 
activity, but also serves to harden the parts, as it were, and 
render them less sensitive to the action of cold. 

Of more importance still, as a preventive measure, is the re- 
moval of that condition which, as already suggested, is really 
the cause of this liability to take cold — the cure of the mild 



176 DISEASES OF THE NASAL CAVITY. 

chronic coiyza which undoubtedly exists in these cases. At this 
time the affection is easily managed by very simple measures, 
and a condition removed which in many cases, at least, will 
eventuallj^ result in chronic nasal catarrh. The special reme- 
dies indicated wdll be noticed when we come to the considera- 
tion of chronic coryza. 

Treatment. — An attack of acute corj^za may often be aborted 
if measures are resorted to for the accomplishment of this pur- 
pose sufficiently early. This must needs be done very soon 
after the first local symptoms show themselves, and, as a rule, 
before the copious discharge has set in. The plan consists in 
the administration of from five to ten grains of quinine, fol- 
lowed by some warm drink, such as chamomile-tea, or a hot 
lemonade, with the addition, perhaps, of a hot foot-bath. The 
object of this, of course, is to produce a copious perspiration, 
and thus restore the animal heat which has been lost, and re- 
establish the proper equilibrium between heat-production and 
heat-waste. If there is much pain over the forehead or neural- 
gic pain in the face, due to involvement of some one of the 
accessory cavities, ten grains of Dover's powder may be given 
with advantage, both for the relief of pain and to aid in pro- 
ducing diaphoresis. 

Cohen advocates warmly the administration of chloroform 
to the extent of producing anaesthesia, claiming that by this 
procedure a coryza may be aborted if the measure is resorted 
to at the onset of the attack, I have never made trial of this 
remedy, and cannot speak from personal experience of its effi- 
cacy. 

After the discharge has set in, as it does in a few hours or 
a day after the onset of the attack, all that can be hoped for is 
to somewhat curtail the duration of the disease and limit the 
inflammatory action. I know of no better remedy for the pur- 
pose than the follomng, which was j)ublished in the London 
Lancet a few j^ears ago : 

3 . Morphiffi sulphat gi'- ij- 

Bismuth subcarbonat 3 J. 

M. Ft. pulv. 

This may be used frequently through the day, a small por- 
tion being snuffed into the nostril every hour or two. It should 




ACUTE COEYZA, OR COLD IN THE HEAD. 177 

be borne in mind, however, that absorption from the nasal 
membrane is quite prompt, and that the constitutional effect of 
the morphia is obtained as well as the local, hence the amount 
used should be carefully noted. I usually prefer to order the 
above prescription to be divided into twelve powders, and di- 
rect that one shall be used every half -hour until very decided 
relief is obtained. The little powder-insufflator shown in Fig. 
92 answers a very convenient purpose in 
these cases,enabling the patient to apply 
the powder thoroughly and effectively. 
If there is much swelling of the 
membrane, with painful obstruction of 
the nares accompanied with frontal 
headache, much relief will be afforded fig. oi.-powderinsufflator for 

, ., •IT,- I! ^ ^ rm • self-use. with an opening in the up- 

by the inhalation oi hot vapor. Tins per branch through which the puw- 

, -, n • der is inserted. 

serves to cause, as it were, a local dia- 
phoresis, thereby relieving the distention of the vessels and pro- 
moting resolution. Chamomile flowers, poppy -heads, oi* hops 
added to the hot water serve an excellent purpose in relieving 
the pain, which is often a prominent symptom. 

If the general diaphoresis which has been resorted to for the 
purpose of aborting tlie coryza fails, it is well to repeat it on the 
second or also on the third night, as much can be accomplished 
thereby in promoting a more rapid resolution of the attack. 

The inhalation of the vapor of iodine has been recommended 
in acute coryza. Any catarrhal affection, whether acute or 
chronic, may be relieved temporarily by the use of an irritant, 
which stimulates the membrane to a copious discharge, thereby 
causing a temporary depletion, and hence, for the time, decided 
relief. It is, however, only temporary, and the advisability of 
the use of such remedies is, to say the least, doubtful. 

As of iodine, so the same may be said of carbolic acid, cre- 
asote, ammonia, etc. 

A remedy of much repute among the Germans, and known 
as Hager's remedy for a cold, is as follows : 

I^ . Acidi carbolici 3 j. 

Alcoliol fort 3 iij. 

Liq. ammonite fort 3 j. 

Aquse destillata? 3 i j. 

M. 

12 



178 DISEASES OF THE NASAL CAVITY. 

A few drops of the solution are to be sprinkled on a liand- 
kercliief, and inhaled through the nose as long as its strength 
lasts. This is to be repeated every two or three hours. I have 
occasionally made use of this remedy with excellent results, 
but generally prefer the Lancet powder. (Page 176). 

Aqueous solutions of the various astringents, such as tan- 
nin, alum, zinc, etc., have been recommended, to be used in 
the form of spray, by the douche, and by insutflation. They 
are of benefit in the later stages of the affection, when the 
muco-purulent discharge has set in, and are especially to be 
recommended if the attack seems persistent and threatens to 
lapse into a chronic coryza. In this case a solution of tannin, 
gr. X.— 3 ]'., alum, gr. v.— 3 j., or sodffi biborat., gr. x.— 3 j., may 
be used. The small atomizer shown in Fig. 63 is better for this 
application thau either the nasal douche or the sjainge. In 
the earlier stages of a coryza aqueous solutions are of doubtful 
benefit. The same may be said of insufflation of salt water, 
tlie smoking of cubebs, etc. 

It is a tradition of old standing that a cold can be arrested 
by the abstention from drinking water for a period of forty- 
eight hours. I have never known of au}^ one succeeding in ac- 
complishing the desired result by this measure, and, moreover, 
lam disposed to doubt if any oite has ever succeeded in faith- 
fully carrying out the plan. 



CHAPTER XII. 

CHEONIC NASAL CATAREH. 

This term is of very ancient usage, and is one which so much 
more completely defines the disease which we are now to con- 
sider than an}^ other, that I prefer to retain it. 

The more recent literature of the subject abounds with a 
large number of names which it seems to me only serve to con- 
fuse. As before intimated, whatever ana tomical division may 
be made of the nasal cavities, from a pathological point of 
view, they may be defined as extending from the nostrils to 
the free border of the soft palate, including the upper pharynx. 
Chronic nasal catarrh, then, may be defined as a chronic in- 
flammation of the mucous membrane lining the nasal cavities 
and the vault of the pharynx. This affection is often desig- 
nated as naso-pharyngeal catarrh. I see no especial advantage 
in the use of the longer name. We also find it treated of 
under such varying terms as post-nasal catarrh, retro-nasal 
catarrh, post-pharyngeal catarrh, glandular hj^pertrophy of 
the vault of the pharynx, and follicular pharyngitis. It is 
also oftentimes the disease called clergyman's sore throat. I 
have never met with any of the above-named diseases in which 
the nasal cavity was not also involved in the morbid process. 
By this I mean, that while the disease of the pharynx may be 
so prominent as to lend reason to such a classification, still it 
is always attended with disease of the nasal mucous mem- 
brane, and the simple name of nasal catan-h more correctly 
describes it. 

Nasal catarrh is met with in five varieties : 1. Cliron'iG 
cort/za — a chronic inflammation of the nasal membrane, charac- 
terized by an excessive discharge of mucus, but marked by no 
prominent structural changes. 2. HypertropluG nasal catarrli 
— a chronic inflammation of the-^nucous membrane, character- 
ized by an excessive secretion of mucus or muco-pus, and also 



180 DISEASES OF THE NASAL CAVITY. 

marked by certain structural changes in the membrane by 
which it is thickened or hypertrophied. This hypertrophy in- 
volves not only the membrane lining the nasal cavity proper, 
but also the glands at the vault of the pharynx. 3. Atrophic 
nasal catarrh — a chronic intlammation of the mucous mem- 
brane in which the glandular structures are involved in such a 
way as to seriously interfere with their function. As the re- 
sult of this the membrane fails of its proper supply of mucus, 
and therefore becomes abnormally dry. This is the so-called 
diy catarrh. It is also designated often as pharyngitis sicca. 

4. Fetid catarrh — a catarrh cliaracterized by a fetid and offen- 
sive discharge, and which, in the large majority of cases, if 
not in all, is the direct result of the atrophic or dry catarrh. 

5. Ozmna — properly a disease of the accessory sinuses, but 
manifesting its symptoms in the nasal cavities. 



Chronic Coryza. 

As the result of repeated attacks of cold in the liead, or as 
a chronic affection from the onset, we find the nasal mucous 
membrane taking on a chronic inflammation, of which the prom- 
inent symptom is an increased secretion of mucus or muco-pus. 
This is voided or gotten rid of either by the frequent blowing 
of the nose, or b\^ that peculiar nasal screatus by which the 
discharge is drawn back into the pharynx, and from thence 
is hawked up and expectorated. The discharge, as a rule, is 
thin, semi-fluid, and easily removed. It consists mainly of 
mucus, witli a copious admixture of 3^oung cells and worn-out 
epithelium, which gives to it a somewhat purulent character. 
There is no marked thickening of the mucous membrane, and 
consequently no interference with normal nasal respiration. 
The discharge is fluid at all times, and the membrane soft and 
moist. There is, therefore, no tendency to dryness of the parts, 
or to the formation of crusts or inspissated masses. The secre- 
tions do not accumulate in the cavity, but are constantly being 
discharged, hence fetor, as the result of decomposition of the 
retained masses, is never a feature of the disease. 

The voice is not affected, nor is the sense of smell impaired, 
the intiammator}" process bein^ probably confined in the main 
to the respiratory portion of the cavity, and not involving that 



CHRONIC CORYZA. 181 

portion of the mucons membrane in which the olfactory nerve 
is distribnted. Reflex seHsibility of the nose is somewhat im- 
paired, hence sneezing is not, as a rule, an accompaniment of the 
affection. The symptoms are somewhat in abeyance during 
warm weather, but are more or less prominent during the damp 
and chilly days of Spring and Fall. The disease is not one which 
gives rise to much annoyance, and does not often present for 
treatment, its main importance being in its 'tendency to go on, 
unless arrested, to the development of one of the later forms of 
catarrh. 

Examination. — On inspection, anteriofly, that portion of the 
mucous membrane which comes under observation, viz., the an- 
terior portions of the septum and the middle and lower turbi- 
nated bones, is seen to present a reddened and congested appear- 
ance, with something of a turgid and purplish look ; the surface 
is moist, and coated with more or less free, loose mucus. The 
cavity of the nose is not encroached upon to any marked extent, 
the space between the septum and the convexity of the turbi- 
nated bones being almost normal. On examining behind the 
palate, the same general appearance of the nasal mucous mem- 
brane will be seen, but the appearances of the upper pharynx 
are more noticeable. The rounded concavity of the vault will 
be seen, not encroached upon by any abnormal thickening or 
growths, but the mucous membrane will present a reddened 
and turgid aspect, its glands swollen somewhat, and their ori- 
fices clogged with a thick, tenacious mucus, which apparently 
hangs in masses from their mouths. This mucus is of a gray- 
ish opaque color, and is secreted in a considerable amount. 
• The main importance of the thorough examination in this 
disease lies, in being able to determine the simple character of 
the affection with reference to the measures of treatment to be 
adopted. If the examination fails to reveal any of the evi- 
dences of the later forms of nasal catarrh described farther on, 
the prognosis is rendered favorable and the treatment some- 
what simple. 

Treatment. — In this, as in other forms of catarrhal disease, 
the first step* in the treatment consists in cleansing the part. 
For this purj)ose the post-nasal syringe is unnecessarj^, the ob- 
ject being to accomplish the desired end with as little irritation 
as possible. The syringe is somewhat harsh and irritating, and 
its use should only be resorted to when other and simple 



182 DISEASES OF THE NASAL CAVITY. 

methods fail. The better method of cleansing is by means of 
the atomizer with the compressed ■ air apparatus. Fail'ing 
these, the Richardson hand-ball spray (Fig. 61) serves an excel- 
lent purpose, or the little atomizer, shown in Fig. 63. For 
cleansing purposes there may be used, borax, gr. x. — 3 j., which 
may be improved somewhat by the addition of common salt, 
gr. XV. — 3 j. One of the best of cleansing solutions, however, 
is Dobell's solutioh, given in the appendix. In this affec- 
tion care must be exercised that the application be not irritat- 
ing, and if it is found that any solution is painful it should be 
reduced in strength. ^Bearing this in mind, use may be made 
of any of the cleansing solutions given in the Appendix. The 
application should be thrown through each nostril, and re- 
peated until the cavities are entirely free from all mucous accu- 
mulation, and seen to be so by inspection. If the method of 
cleansing by making application through the nostrils fails to 
remove the mucus from the vault of the pharynx, the part may 
be reached by throwing the spray up behind the palate. For 
the accomplishment of this procedure the parts should be thor- 
oughly relaxed, and the space between the palate and the pha- 
ryngeal wall open. Most patients involuntarily close this 
space the instant any attempt is made to manipulate in the 
fauces, so that the spraying from behind the palate is not easy 
of accomplishment. Cleansing must then be accomplished by 
the use of the s^ainge, or a sponge maybe dipped in the solution 
and passed up behind the palate and the parts swabbed in such 
a manner as to thoroughly remove the accumulations. The 
parts having been cleansed the next step consists in the appli- 
cation of a mild astringent. The best o£ these is tannic acid*, 
which may be used in the form of the officinal glycerole 
( 3 ij. — 3 j.)? one part in eight of water. If there is much con- 
gestion of the membrane the mineral salts may be used with 
advantage, such as alum, ferric alum, or sulphate of iron of a 
strength not greater than four grains to the ounce. If these 
solutions are not well borne resort, may be had in the order of 
preference to one of the following: Potassse chloratis, 3]*.— 
3J.; tinct. kino, 3j. — !j.; tinct. rhatany, 3j.— !j.; zinci sul- 
phat., gr. v.— 3]. 

These can be applied best by means of the atomizer. That 
the medicated fluid thoroughly reaches the parts by this 
method is evidenced by the fact that a cloud of spray can be 



CHRONIC CORYZA. 183 

seen issuing from tlie other nostril. Tliisisone of tlie forms ot 
catarrli in which powders do excellent service, their advan- 
tage being that they are dissolved in the secretions which are 
always Unid, and thus for some time remain in contact with 
the membrane, whereb}^ their astringent action is prolonged. 
It should always be borne in mind, however, that the powders 
should be deposited in such a way that they become evenly 
distributed over the membrane. This is best accomplished by 
the use of the powder-blower, shown in Fig. 47. There may 
be used in this form any of the astringent remedies recom- 
mi-nded to be used in solution, as follows : 

. Acidi tannici 3 j. 

Pulv. amyli 3 vij. 

M. 

Ferri et aluminis sulph 3 j, 

Pulv. amyli § J. 

M. 

I^. Aluminis sulph 3j. 

Pulv. amyli 5 j. 

M. 

IJ . Potass, chlorat 3 ss. 

Pulv. amj^li | j. 

M. 

IJ . Ferri. sulphat 3 j. 

Pulv. amyli |J. 

' M. 

I^. Bismuth subcarb., 

Lycopodii , . aa 3 ss. 

M. 

For the starch in the above 2:)]"escription$ tliere may be sub- 
stituted magnesia, lycopodium, pulv. acacia, or any light neu- 
tral powder. 

Ill addition to the foregoing plun of treatment, which sliould 
be carried out at the hands of the pliysician at least twice each 
week, there are certain measures tlie patient may with profit 
carry out during the intervals of the visits to his physician. 



184 DISEASES OF THE NASAL CAVITY. 

Tlie Weber nasal douche, which has been much abused for 
its inefficiency and for its dangers, may in this disease be 
used not only with entire safety, but with decided benefit, it 
being probable, as above remarked, that tliis affection is largely 
confined to the lower portion of the nasal cavity, and as the 
douche reaches thoroughly that portion of the cavity, we have 
ever}^ reason to suppose that the entire diseased membrane is 
bathed by remedies applied in this manner ; hence, in treating 
a catarrh of this variety, it is well to direct the patient to use 
the nasal douche once a day. The fiuid to be used may be 
one of the cleansing solutions given above, with the addition 
of a mild astringent, such as have been given. Occasionally 
it may be well to direct a snuff to be used in the intervals of 
treatment for this purpose. Any of those given above may be 
prescribed. These should be used with a powder blower in 
preference to being snuffed up in the ordinaiy method. Fig. 92 
shows a convenient little instrument devised for this purpose. 

The ^nno3^ance arising from this form of catarrh is often so 
moderate that patients are not disposed to place themselves 
under a regular course of treatment. In these cases it becomes 
necessary to suggest some simple plan which the patient can 
and will carry out faithfully. The nasal douche involves 
considerable trouble in preparation, and is often objected to. 
The atomizer shown in Fig. 63 involves but little trouble. It 
can be kept on the toilet table and used night and morning, 
and is quite an efficient instrument in these mild catarrhs. 
The remedy to be used in any case will easily suggest itself 
from what has already been said. 



HrPERTKOPiiic Nasal Catarrh. 

A mucous membrane having become the seat of an infiani- 
niatory process which has lapsed into the chronic state, the 
morbid activity is greatest, as we have already seen, in the 
deeper layers of the tissue ; and sooner or later this results in 
a proliferation of all the normal elements of the membrane, 
giving rise to a true hypertrophy. 

This tendency is more marked in the nasal cavity, perhaps, 
than in any other of the mucous tracts, and for several reasons. 
The nasal passages are composed of rigid walls, and are trav 



HYPERTROPHIC NASAL CATARRH. 185 

ersed by the current of air in respiration, and virtually notliini^ 
more. The results of the inflammatory process therefore tend 
not only to accumulate in the superlicial laj^er of the mem- 
brane, but also to infiltrate its meshes, the surface of the 
mucous lining being so entirely protected from attrition or 
pressure that the hypertrophic process is unimpeded. We find, 
therefore, that sooner or later a chronic coryza develops into 
the later form of the disease, which we designate as the hyper- 
trophic form. This is the disease generally spoken of as nasal 
catarrh, and is the one which, in the very large majority of 
cases, presents for treatment when the morbid process has so 
far progressed as to demand relief for symptoms due to the 
nasal disease itself, or its resultant pharyngeal or laryngeal 
catarrh. 

In the nasal cavity ]Droper, the raucous membrane in a state 
of chronic infiammation which has advanced to the stage of 
hypertroph}^, assumes a form somewhat different from that 
generally met with in the pharyngeal vault. In the nares, as 
we know, the lining membrane is not so richly endowed with 
glands as is the case with the lining of the vault of the 
pharynx. Hence, in chronic infiammation the morbid process 
shows itself in certain changes occurring in the mucous mem- 
brane proper. These changes consist in the deposit in the deej) 
la^^ers of the membrane of new connective-tissue elements, and 
an infiltration of the deeper layers with new cells. At the 
same time, in the epithelial elements there is a morbid activity 
in cell-growth by which this layer becomes abnormally thick- 
ened and hypertrophied. We have a true hypertrophy of the 
membrane involving all the normal elements of the part, the 
greatest activity, however, of the process being confined to the 
connective - tissue elements and epithelium. The glandular 
structures are involved also, but to a limited extent. The re- 
sult of this process, in its infiuence on the normal function of 
the parts, is simply to increase the secretion of mucus, and 
give to it somewhat of a purulent character by the admixture 
of young cells with the discharge. This thickening does not 
occur in a smooth, uniform hypertrophy, but shows itself in a 
somewhat irregular, and in places nodular, appearance. Its 
usual site is on the convexity of the turbinated bones, and, 
in fact, in this locality the morbid process is developed in its 
greatest extent. The lower turbinated bone, as a rule, is more 



186 DISEASES OF THE NASAL CAVITY. 

involved tLan tlie middle, and the middle more than the upper. 
The membrane of the septum is also affected on one or both 
sides. The floor of the nares is not ordinarily involved. 

Symptoms.— HhQ prominent symptoms resulting from this 
condition are, an abnormal secretion of mucus or muco-pus, 
together with a narrowing or stenosis of the nasal cavity, giving 
rise to an interference with free nasal respiration. Tlie mem- 
brane becomes also extremely irritable and sensitive to changes 
of the weather. The excessive discharge does not, as in acute 
coryza, make its way toward the nostrils anteriorl}', but is 
drawn back into the fauces, whence it is hawked up and ex- 
pectorated. It is frequently poured out in such an excess that 
it gives rise to a constant dropping in the throat, a symptom 
of which patients often complain, and which gives rise to no 
little annoyance and discomfort. The origin of this discharge 
has been attributed to the pharyngeal tonsil, and again to the 
sphenoidal sinuses, to the ethmoid cells, etc. The source of 
much of the discharge in this form of catarrh is unquestionably 
in the glandular structures at the pharyngeal vault, but its 
principal source is in the hj^pertrophied membrane in the nasal 
cavity proper. This I have frequently verified by the success 
in arresting it by measures of treatment directed to these parts 
alone. That the sphenoidal sinuses or ethmoid cells are involved 
in the disease, and become a source of abnormal discharge, is 
undoubtedly a mistake. 

There is no tendency, as a rule, to the formation of crusts 
or inspissated masses, nor are fetid and offensive secretions an 
accompaniment of this form of catarrh. If such a symptom 
should be present it would be an evidence that some other form 
of the disease was to be dealt with. The secretion is greatly 
increased, and as the morbid process develops, becomes thick, 
ropy, and extremely tenacious, with more or less of an admix- 
ture of young cells which give it a semi-purulent character, its 
color being yellowish and opaque. This discharge passes 
down and lodges between the soft palate and pharjnigeal wall, 
giving rise to much annoj'ance and irritation, with a feeling as 
of a foreign body in the throat, which the sufferer makes in- 
effectual efforts to remove by swallowing. Failing in this he 
resorts to a disagreeable nasal screatus, by which he endeavors 
to detach it, and draw it down into the lower pharjnix. The 
outljdng glands lower down on the pharyngeal wall, below the 



HYPERTROPHIC NASAL CATARRH. 187 

border of the soft palate, are also involved in scattered groups. 
As the disease becomes more chronic, the lower. pharynx be- 
comes involved, not necessarily as a result of the direct exten- 
sion of the disease, but from the excessive secretion which 
flows dow^n over its surface, together with the deleterious in- 
fluence of the oral breathing compelled by the nasal stenosis. 
This is aggravated somewhat by the violent efforts at hawking 
and clearing the throat, which become necessary on account of 
the mucus which accumulates there. 

The discharge, passing down the wall of the pharynx, reaches 
the arytenoid commissure and passes into the larynx, giving 
rise, oftentimes, to a chronic laryngeal catarrh, as a result of 
the irritation thereby set up. Cough sooner or later sets in, 
of a more or less aggravated character and reflex in nature, 
being excited in the effort to clear the fauces of the irritating- 
secretions. This, as a rule, occurs in the morning, when the 
secretions have accumulated over night, and during the pro- 
longed abeyance of any voluntary effort to relieve the throat. 
The voice is affected somewhat in character and register, ac- 
cording as the laryngeal symptoms are pronounced. It is also 
affected somewhat by the extent of the" hypertrophy occurring 
in the nasal cavity and vault of the pharynx, but only to the 
extent by which these cavities are encroached upon by the 
thickened membrane, and thereby tlie special vibrations inter- 
fered with, which give the voice its normal nasal character. 
Hearing may be interfered with by the hyper trophied tissues 
encroaching upon the orifice of the Eustachian tube, or by the 
inflammatory process extending into the tube. The extent of 
this impairment, of course, being dependent on the extent of the 
morbid process. 

As a result of this hypertrophy the nasal cavity is en- 
croached upon, and to such an extent often as to interfere 
with nasal respiration. This stenosis may be so great as to 
cause no little annoyance or distress to the sufferer. The mem- 
brane is also extremely irritable and sensitive to any changes 
in the weather; especially is it aggravated by a combination of 
cold and dampness, under the influence of wliich it seems to 
become swollen and puffy, as it were, thus increasing the diffi- 
culty of nasal respiration, and at the same time pouring forth 
a copious watery discharge mixed with mucus. This exacerba- 
tion of the ordinary sj-mptoms is not so much due to taking 



188 DISEASES OF THE NASAIJ CAVITY. 

cold, as to tlie direct irritating influence of tlie damp atmos- 
phere coming in contact with the membrane. In tliis it re- 
sembles somewhat the hj^groscopic character of the gelatinous 
polypus of the nose. The symptoms of the disease during these 
exacerbations become not unlike an attack of cold in the head 
in other respects also, in that the swelling of the membrane 
may lead to a closure of the frontal sinuses, resulting in more 
or less intense frontal headache. The involvement of the an- 
trum of Highmore may lead to facial neuralgia. There may 
be also sj'mpathetic irritation of the eyes, etc. 

Fjxaiui nation anteriorly. — If, now, we make an examina- 
tion anteriorly, the nostril being dilated and the tip of the nose 
elevated, we see projecting into the cavity the anterior termina- 
tion of the inferior turbinated bone, with its membrane thick- 
ened in such a manner as to encroach very decidedly on the 
normal breathing space of the passage. The membrane is red- 
dened and congested, and is coated with more or less of a 
humid and watery discharge, and if the thickened tissue pro- 
jects to such an extent as to touch the septum there may be 
noticed a superficial erosion at the point of contact. It is soft 
and somewhat doughy to the touch, and if indented with a 
probe recovers its convexity sluggishly. The septum presents 
a somewhat irregular aspect, projections being noticed which 
here and there destroy its normal smoothness of contour. The 
discharges as seen from the front, as a rule, in this form of 
catarrh, are still fluid mucus, though they oftentimes have a 
thick and ropy character. 

If now the face of the patient be loAvered in such a manner 
that the floor of the nares with the lower meatus can be 
brought into view, it will be seen that the membrane covering 
the lower turbinated bone seems to hang downward, thus en- 
croaching on the lower passage. This may be the case to 
such an extent that the hypertrophied tissue lies upon or 
touches the flow of the nares. By throwing the head back- 
ward now, the middle turbinated bone can be easily seen, 
and if involved in the morbid process will present much 
the same appearance as the lower. It will be seen projecting 
toward, and oftentimes in contact with the septum. It gen- 
erally presents a rounded mass to the view, and does not 
show the same tendenc}^ to project downward as is manifested 
in the lower turbinated bone. 



HYPERTROPHIC KASAL CATARRH. 189 

Examination poster iorly. — If now the nasal cavity be in- 
spected from behind, by means of the rhinoscopic mirror, con- 
lining the examination to the nasal fossae proper, there will 
be brought into view, under ordinarily favorable circumstan- 
ces, the superior and middle turbinated bones and the upper 
half of the lower turbinated bone with the larger portion of 
the septum. The membrane over these parts, as far as the}^ 
are involved in the hypertrophic process, will be seen covered 
by a mucous membrane presenting appearances peculiar and 
characteristic. Over the turbinated bones the membrane is 
raised and projects prominently from the convexity, is some- 
what whitened or blanched in appeai'ance, of a whitish-gray 
color, with an irregular corrugated surface, its outline marked 
by seams or fissures. The appearance resembles that of a grub- 
worm in outline, color, and in the seamed appearance of the 
surface. This condition is most prominent over the lower turbi- 
nated bone, as a rule, but maj^ be seen on the middle and upper. 
It is seen, in both cavities, though generally to a somewhat 
greater extent in one than in the other. The septum is also 
involved in the same process, and on inspection there will be 
seen bulging from either side the same peculiar thickening of 
the membrane which serves to encroach still further on the nor- 
mal lumen of the cavity. This grub-worm thickening is char- 
acteristic and peculiar, and when once seen will always be 
I'ecognized. It is the essential condition which constitutes hy- 
pertrophic nasal catarrh, and may exist to but slight extent, 
merely deforming the surface of the membrane and giving rise 
to a shallow thickening ; or it may exist to the extent of en- 
croaching very seriously on the nasal cavity. It is usually 
well marked on the middle turbinated bone, but far more so, 
as a rule, on tlie lower, which will be seen presenting a large, 
rounded, corrugated mass, encroaching on the posterior nares, 
and liaving the appearance of a tumor lying on the tloor of the 
cavity. 

Turning now to the vault of the pharynx, we find here a mu- 
cous membrane so richly endowed with glands that it is often 
spoken of as the pharyngeal tonsil. Here also, as in the nasal 
cavity proper, chronic inilamnuUion results in a hypertrophy 
of the membrane, but of a different character, in that the 
glandular structures are mainly involved in the morbid process 
rather than the mucous membrane proper. The glands be- 



190 DISEASES OF THE NASAL CAVITY. 

come enlarged, their cavities distended, their walls thickened, 
and we have a true glandular hypertrophy characterized by a 
deposit of connective tissue in the deep layers of the mem- 
brane, and also in the coats of the glands, together with an 
increase In the epithelial cells and blood-vessels, and other of 
the normal elements of the tissue. 

If now we examine this region by the aid of the rhinoscopic 
mirror, in place of the rounded dome-like cavit^y of the vault, 
which is seen in the normal health}^ condition of the part, we 
shall find the mucous membrane thickened and nodulated, raised 
markedly above the surface in parts, and traversed by seams 
and fissures, the projections presenting small, rounded, turgid 
masses, gathered together in clusters. These may protrude so 
far as to piresent hemispherical bodies, or simple, small, rounded 
masses projecting and raised above the surface. In other places 
these elevations show themselves as elongated ridges, whose 
general direction is from above downward. The color varies 
from a rose color to a deep purple. In the upper portion a 
deep transverse fissure will be noticed, which marks the rather 
abrupt termination between the roof of the nasal cavity proper 
and tlie phar^nigeal tonsil. In the lower portion, and in the 
median line, there will be generally noticed a small circular 
opening, the orifice into a small pouch, the pharyngeal bursa. 
The parts are generally seen to be covered with a thick pendu- 
lous mass of mucus, which seems to be entangled in the meshes 
of the glands, and hangs down between the soft palate and 
posterior pharyngeal wall. 

Removing the mirror, and simply examining the lower 
pharynx by direct insiDection, the mucous membrane will be 
seen reddened, somewhat thickened, and marked by small, 
scattered, and rounded eminences, which are the outlying folli- 
cles of the phar^-ngeal tonsil involved in the same hypertro- 
phic process. They are grouped in the upper portion of the 
lower phaiynx, and along the border of the pillars of the 
fauces. If the palate is touched, in order to excite a moder- 
ate reflex contraction, it is drawn up against the posterior wall 
of the i3harynx, and there is seen lodged in the angle, beneath 
the uvula, the mass of ropy mucus which is protruding from the 
ni)per pharyngeal glands. 

The treatment of nasal catarrh becomes of importance from 
a number of considerations. It is much to be deprecated that 



HYPERTROPHIC NASAL CATARRH. 191 

in the milder and more tractable forms the sufferer so rarely 
seeks relief at the hands of the physician. The limited 
amount of the abnormal secretion which is discharged an- 
teriorly, or is drawn back into the fauces and hawked np and 
expectorated, is merely the source of a moderate degree of 
annoyance during the Spring and Fall months, when the dis- 
ease is somewhat aggravated by atmospheric conditions. Dur- 
ing other portions of the year the sufferer is comparatively 
free from any trouble. At this time, then, the disease is only 
serious in its tendencies toward the develoj)ment of the later 
and graver forms of nasal catarrh, or, possibly, other affections. 
In many cases the natural sequence of events may be predicted 
with considerable certainty as follows : the simple coryza grad- 
ually progresses to the development of hypertrophied tissue, 
both in the nasal cavity and in the vault of the pharynx, with 
the ordinary s^anptoms which accompany the disease ; there 
is an excessive liability to take cold, and each exacerbation 
leaves behind it an increase of the chronic inflammatory pro- 
cess. The disease advancing to the lower pharynx and larynx, 
we find these organs involved in the acute attacks which recur 
with renewed frequenc}^ and on slighter provocation, and it soon 
becomes a not unusual occurrence that the trachea and larger 
bronchi become involved. While the general health is unim- 
paired, these attacks- are readily thrown off, but there is al- 
ways a danger that from impaired health or lowered vitality 
from any cause, an attack of bronchitis may occur, which is 
not recovered from with readiness, and that, eventually, a more 
permanent and graver trouble may occur in the lungs. That 
this is a possible sequence of events, and is one of the dangers 
of chronic inflammations in the upper air-passages, cannot be 
questioned, although it is undoubtedly true that a very large 
proportion of cases of nasal catarrh may exist for years without 
extending to the lung- tissues. 

Treatment. — In this affection the secretions accumulate not 
only on the face of the turbinated bones, but in the sinuosities of 
the cavities, and being of a thick and ropy character often, they 
form a shield to the parts which, unless it is removed, completely 
bars the access of topical agents. In the failure to recognize 
this fact we have possibly a partial explanation of the frequent 
inefficacy of local treatment in the management of the disease. 

It is of the flrst importance, then, tliat the membrane shall 



192 DISEASES OF THE NASAL CAVITY. 

be tlioi'onghly cleansed of its mucus as the first step in treat- 
ment, and before the especial remedy is applied whose local 
action it is desired to obtain. If the disease is moderate in ex- 
tent, and the secretions thin, fluid, and easily detached, this 
may be accomplished by the use of the atomizer, the current 
being thrown into the nostril. The Richardson spray (Fig. 61) 
or the small atomizer shown in Fig. 63, will accomplish this 
quite efficiently ; but in ordinary cases a far more satisfactory 
means is by the use of the compressed air apparatus with 
Sass's tubes, the spray being thrown in flrst at one nostril, 
then at the other, each application being followed b}^ the 
moderate blowing of the nose. By this method the whole 
nasal cavity, as also the vault of the pharynx, is thoroughly 
flooded with the medicated fluid. If, however, the hypertro- 
phic process has advanced to the extent of producing a marked 
narrowing of the nasal cavity, the application to the pharynx 
through the anterior nares is rendered more difficult. We 
must then have resort to the upward spray, shown in Fig, 62, 
by which the cleansing fluid is thrown into the nasal cavity 
from behind the palate. This, however, is a somewhat diffi- 
cult procedure, as the proper control of the movements of the 
palate is essential for its accomplishment, and, as a rule, pa- 
tients are unable to propeily manage this, and, as has been 
said before, palate-retractors are not well tolerated. We are 
then compelled to resort to some measure of cleansing, in the 
accomplishment of which lack of training on the part of the 
patient does not interfere. The post-nasal syringe shown in 
Fig. 54 answers this purpose, in that its beak is easily i3assed 
behind the palate in whatever position the fauces may be, and 
its contents delivered in such a way as to thoroughly and ef- 
fectually bathe the lining of the whole nasal cavity and vault 
of the pharynx. The essential feature of any method of cleans- 
ing of the nasal cavity is that the solutions shall thoroughly 
reach (he parts with which thej^ are intended to come in con- 
tact, and also that they shall reach them in such a manner as 
to completely detach the mucus which there exists. In mild 
cases of nasal catarrh, the anterior nasal cavity is quite patu- 
lous, and the spray apparatus accomplishes this purpose very 
satisfactorily ; but in those cases, in which the cavity of the 
anterior nares is encroached upon by hypertrophied tissue, we 
have no resort that approaches in efficiency the use of the post- 



HYPERTROPHIC NASAL CATARRH. 193 

nasal syringe for cleansing purposes. In Fig. 55 there is 
shown the nozzle of this syringe, which may be attached to 
the Davidson or fountain-syringe, and used for the same pur- 
pose. It oftentimes becomes necessary, however, to throw the 
fluids with a degree of force, which can only be secured by the 
use of the barrel-syringe. As regards the use of the Weber 
douche for cleansing in the treatment of this form of nasal 
catarrh, its inefficiency has been sufficiently alluded to in a 
previous chapter. The fluids to be used may be any of those 
given in the Appendix. The Dobell's solution (Prescription 
]N'o. 1) I have always found by far the most usef al. Occasion- 
ally it gives pain, in which case it may be diluted, or the 
amount of carbolic acid lessened. 

After the parts are thoroughly cleansed they are ready for 
the next procedure, which consists in the application of such 
astringent or resolvent as may be especially indicated. The 
special remedy decided upon is best applied in the form of 
spray, and, as has been said above, Sass's spray-tubes with the 
compressed-air apparatus furnish the most efficient means we 
have of reaching thoroughly the whole cavity. This apparatus 
not being at hand, resort may be had to the Richardson's hand- 
ball spray. 

If the disease is moderate in extent, and not attended with 
any marked degree of hypertrophy of the membrane, complete 
resolution may be accomplished by the application of aqueous 
solutions. For this purpose there are very few of the various 
astringents of the pharmacopoeia but have been used. With- 
out enumerating these in detail, there are given in the order of 
preference such as have been found beneficial in these cases : 
sulphate of zinc, gr. v. — x. to ?J., chloride of zinc, gr. ij, — vj. 
to 2J., tannin, 3 ss. — 3J., chlorate of potash, 3j. — fj., nitrate 
of silver, gr. j. — iij. to § j. These should be applied in a very 
limited amount, all that is desired being merely to ap]3ly a 
thin coating of the solution to the membrane. The selection 
in each case of the special remedy to be used, must necessarily 
depend somewhat on the tolerance and the effect, keeping in 
view the fact, that it is not well to apply any fluid to the nasal 
cavity, which causes pain or irritation. 

The nasal cavity, however, is oftentimes so sensitive that 
any application gives rise to pain more or less intense in char- 
acter. This should be corrected Immediately. This pain may 
13 



194 DISEASES OF THE NASAL CAVITY. 

be caused by an over-sensitive membrane, or by the irritating 
qualities of the solution used. As a rule, it can be relieved 
by throwing in immediately an alkaline solution such as has 
been recommended for cleansing purjooses, and preferably the 
Dobell's solution. Occasionally the application of aqueous so- 
lutions gives rise to severe frontal or facial neuralgias. This 
is due generally to the solution, of too low a temperature, mak- 
ing its way to the frontal sinus or the antrum of Highmore. 
This is an accident liable to happen to the most careful opera- 
tor, and cannot always be avoided by the exercise of even the 
greatest care. When the accident does occur, the pain should 
be brought under control as rapidly as possible by the use of 
anodyne and soothing applications. The readiest method of 
controlling it, is by throwing into the nostril a powder contain- 
ing from one-sixth to one-fourth of a grain of morphine, com- 
bined with a small amount of subcarbonate of bismuth and 
carbonate of magnesia. In many cases the use of solutions of 
mineral astringents, or in fact solutions of astringents of any 
kind, are not well tolerated. In these cases there may be sub- 
stituted the use of a powder with very excellent results. These 
may be applied by means of the powder-blower shown in Fig. 
47, after the parts have been thoroughly cleansed. For this 
purpose there may be used one of the following : 

I^. Acidi salicylici gr. x. 

Bismuth subcarb., 

Tannin aa 3 i. 

M. 

I^ . Arg. nitrat gi'- ij- 

Bismuth subnit 3 ij. 

M. 

I^. Zinci sulphat 3j. 

Pulv. acacia, 

Magnesias carb aa 3 ij. 

M. 

I^ . Zinci chloridi gr- "^• 

Pulv. belladonna gr. x. 

Pulv. amyli I ss. 

M. 



HTPERTKOPHIC JS'ASAL CATARRH. 195 

B}^ the above indicated plan of treatment, mncli can be 
accomplislied in mild cases of the hypertrophic catarrh. If 
the disease is not one of long standing, and the neoplastic tis- 
sue is of comparatively recent origin, and has not had time to 
become thoroughly organized, complete resolution may be con- 
fidently anticipated, if the treatment is carried out efficiently 
and persisted in for a sufficient length of time. 

In the more advanced cases of catarrh, however, in which 
the new tissue has become firmly organized, and in which the 
morbid process involves a large extent of the naso-pharyngeal 
membrane, and in which the nasal cavity is seriously encroached 
upon by the neoplastic tissue, the plan of treatment above in- 
dicated will fail to more than alleviate some of the prominent 
symptoms of the disease ; and it is these cases which form the 
great bulk of the cases of nasal catarrh that present them- 
selves for treatment. 

When the plan of treatment by atomization was first intro- 
duced, great results were anticipated. The same may be said 
of the Weber douche. It is undoubtedly true that the appli- 
cation, by these devices, of aqueous solutions of astringents, 
resolvents, etc., will do very much to relieve an advanced nasal 
catarrh ; but that it often cures the disease is extremely doubt- 
ful. As before stated, the excessive secretion which is so 
prominent a feature of the afi'ection, has its source largely in 
this hypertrophied tissue, and any astringent applied to it un- 
doubtedly limits or keeps in abeyance the discharge, but the 
tendency is to a return of the trouble soon after the treatment 
is abandoned. 

The proper treatment, then, must be of a more radical 
character, and must involve the use of some means by which 
the hypertrophied membrane can be destroyed. Hence, the 
successful treatment of nasal catarrh depends oh the recog- 
nition of the form of the disease with which we have to deal 
in each individual. It is not intended in the compass of this 
article to discuss all the measures which have been resorted to 
for the accomplisliment of the destruction of this hypertro- 
phic tissue, but simply to enumerate the more prominent ones, 
and briefly to discuss their advantages and disadvantages, with 
the especial methods b}'' which they may be used. 

In this connection there should be mentioned a plan, first 
suggested by Dr. Wagner of New York, by which the attempt 



196 DISEASES OF THE NASAL CAVITY. 

is made to get rid of this neoplastic tiss^^e by producing absorp- 
tion. This is accomplished by the introduction of sponge- 
tents, so shaped that they can be inserted between the convex- 
ity of the turbinated bones and the septum, when, on imbibing 
moisture from the parts, they swell up and exercise pressure 
on the hypertrophied mass, thereby inducing atrophy. They 
are intended, of course, to remain in situ for several hours. 
This procedure is to be repeated at intervals, for a considerable 
length of time. The nose is extremely intolerant of the pres- 
ence of a foreign body, and the time during which the sponge- 
tent remains, is one of considerable discomfort to the patient, 
on account not only of the complete closure of the nostril 
which it involves, but also on account of the irritation and pain 
which it excites. It is also somewhat difficult to so locate the 
sponge, that it will exercise an equable pressure on more than 
the convexity of the turbinated bone, whereas the hypertrophic 
tissue grows downward toward the flow of the nares as well as 
inward. It is questionable, therefore, whether this plan of 
treatment affords more than temporary relief. 

Another method, recommended I believe also by Dr. Wag- 
ner, is that of passing metal bougies through the nasal cavity, 
thus dilating it after the plan of treating urethral strictures, in 
those cases in which the hypertrophy of the membrane has pro- 
duced a stenosis of the passage. This is open to the same objec- 
tion that was made to the use of sponge-tents ; it gives but tem- 
porary relief. We know that the passage of any small probe 
through a "stopped up" nose will open it up for the time to 
the passage of air, and give decided relief to the discomfort of 
the patient. This relief, however, is but temporary, and it is 
extremely doubtful if any permanent good is accomplished. 

Resource must then be had in the use of some destructive 
agent to remove the offending tissue. Those which we will 
enumerate, and briefly discuss are, the forceps, nitric acid, 
chromic acid, nitrate of silver, acetic acid, the actual cautery, 
and the galvano-cautery. 

The forceps. — This instrument consists of a long-bladed 
stout pair of forceps, with a firm bite, and a row of teeth in 
the side of the blade. It is so fashioned that it can be in- 
troduced well into the nasal cavity, and the offending tissue 
being seized, is torn and wrenched out by brute force. Fig. 
93 shows the forceps devised by Dr. B. Robinson for this pur- 



HYPERTROPHIC NASAL CATARRH. 



197 



pose. The operation is an extremely painful one ; is attended 
oftentimes with a considerable degree of hemorrhage ; it is 
done necessarily in a somewhat hap-hazard way, as the flow of 
blood obscures the parts after the first manipulation ; and it 
is difficult to avoid tearing away more of the tissues than is 
desirable — healthy membrane, periosteum, and even portions 
of the turbinated bone being liable to be torn out.. We have 




. — Robinson's forceps for removing hypertrophied tissue from the nose. 



too many simpler, less painful, and more efiicient methods to 
warrant us in subjecting the nasal cavity to such rough usage. 
Nitric acid. — This is an extremely powerful destructive 
agent, but one great objection attending its use, lies in the diffi- 
culty of nicely localizing its action, and preventing its spread- 
ing to the health}^ tissues. This difficulty has in a measure 
been overcome by an ingenious little device of Dr. A. H. Smith, 




Fig. 94. — Smith's canula for applying caustics to the turbinated bones. 



of New York, shown in Fig. 94. Tiiis consists of a small flat- 
tened tube of glass or hard rubber, in the distal extremit}^ of 
which there is cut a small oval fenestrum. The tube is passed 
into the nasal cavity, and so placed that the membrane which 
it is designed to cauterize, pouches into the fenestrum. A 
probe wrapped with cotton is then dipped into the acid, and 
passed into the tube, until it reaches the opening. In this 
manner the cauterization is confined to the membrane lying 
against the opening of the tube. This procedure may be re- 



198 DISEASES OF THE NASAL CAVITY. 

peated until all the offending tissue is destroyed. Using some 
such device as this, nitric acid is an extremely valuable agent 
in the treatment of these advanced cases of nasal catarrh, and 
excellent results may be obtained by its use. It is mainly 
valuable for application to the hypertrophied membrane over 
the turbinated bones, being applied through the nostrils. It 
is not a safe caustic for application to the vault of the pha- 
rynx, as there woald be danger of its dropping down the pha- 
ryngeal wall, and making its way into the larynx, which might 
be an extremely serious mishap. The main objection to the 
nitric acid lies in its great activity as an escharotic, by which 
more tissue may be destroyed than is desirable, or a too deep 
eschar may be formed which may result in a troublesome 
ulceration. 

Chromic acid. — This is highly recommended by many, both 
for application to the turbinated bones and to the vault of the 
pharynx. It is a powerful escharotic and its use is compara- 
tively painless. It possesses, also, in its acicular crystals, the 
advantage of a very convenient form for making the applica- 
tion. These can be easily taken up on a small probe, wrapped 
with a fine film of cotton, and carried directly to the part it is 
desired to destroy. The method of cauterizing the turbinated 
bones is sufficiently obvious. In reaching the glandular tis- 
sues at the pharyngeal vault, a properly curved probe is neces- 
sar}^, b}^ the aid of which the acid may be carried directly to 
the part. By the use of a little deftness of manipulation, this 
procedure can be accomplished without tying back the palate, 
although it is better to do this, if the throat is very irritable 
and there is danger of injuring the healthy parts. It is best, 
as a rule, to use but a veiy few of the small crystals for each 
application. Occasionally it may seem well to use a saturated 
aqueous solution of the acid, but the crystals are more easily 
manipulated, and there is less danger with them of the cauter- 
ization extending farther than is desirable. 

Nitrate of silver. — Probably no caustic has been used and 
abused to the same extent that nitrate of silver has. In mild 
solutions I regard it as one of the most valuable of all astrin- 
gents. In the form of the solid stick, or strong solutions, I am 
disposed to think it has been responsible for more mischief 
than benefit in catarrhal diseases. It is a mistake to regard it 
purely as an escharotic, it is also a powerful stimulant, and 



HYPERTROPHIC NASAL CATARRH. 199 

lierein probably lies its efficacy in certain forms of ulceration. 
When applied to the hypertrophic membrane in chronic nasal 
catarrh, whether to the turbinated bones or to the vault of the 
pharynx, it undoubtedly destroys the superficial layer of the 
membrane, causing an eschar which is soon thrown off ; by its 
stimulating properties, however, it sets in play certain struc- 
tural changes in the deep layers of the membrane, which are 
liable to more than counterbalance the good that has been 
accomplished b}^ the superficial destruction. 

I formerly resorted quite frequently to the use of this 
caustic in hypertrophic catarrh, being led thereto possibly by 
its facility of application, but have almost invariably been dis- 
appointed of any permanent good results, and in many cases 
have undoubtedly done harm. The subjective symptoms re- 
sulting from its use also, it may be stated, are of a somewhat 
unpleasant character, as its immediate effect is to cause con- 
siderable pain and swelling of the parts. 

It may, however, occasionally seem well to make use of this 
remedy in some of the milder, and somewhat localized hyper- 
trophies. In these cases it should be added, that it is not well 
to use the ordinary caustic-holder in making the application to 
any portion of the air-passages, but the caustic should be fused 
on a properly fashioned probe. We are usually taught that a 
platinum or aluminium probe is necessarj^, but an ordinary 
brass or copper wire answers an excellent purpose. This may 
be flattened and bent in the proper shape, and then, by taking 
a few crystals of the caustic upon it and holding it over a gas- 
jet or spirit-lamp, the crystals are melted into a small bead, 
which adheres closely to the probe, and can be carried safely 
to the part it is designed to cauterize without incurring the 
danger of their falling off. 

Acetic acid. — The well-known affinity of this agent for epi- 
thelial cells, and its action on the localized hypertrophies of 
the superficial layers of the integument, would suggest its use 
in those hypertrophic thickenings of the mucous membrane in 
which the epithelial layer plays a j^rominent part. This is the 
case in the changes which occur in the lining of the nasal 
cavity proper, in the form of catarrh under consideration. In 
this agent, then, I think we have a method of destroying this 
thickened tissue which possesses most of the advantages and 
few of the disadvantages which attend the use of any of those 



200 DISEASES OF THE NASAL CAVITY. 

already alluded to. It is not well adapted for use in the vault 
of the pharynx, but for application to the nasal cavity proper 
it is a most excellent remedy. It is efficient in destroying tis- 
sue, it is easy of application, it causes no secondary inflam- 
mation, it does not cause too much destruction of tissue, and 
thereb}^ the danger of subsequent troublesome ulceration, and 
it is easily tolerated. 

The manner in which it may be applied is as follows : a self- 
retaining speculum being introduced, a flattened probe, bent at 
an angle of 150° (Fig. 95), is wTapped with a small pellet of 
cotton and dipped in the acid, and passed rapidly through the 
cavity between the lower turbinated bone and the septum, to 
be repeated with the middle and upper bones if they are af- 
fected. The application is somewhat painful, of course, but 
the pain can be instantly relieved by throwing in by the atom- 
izer, a solution of common salt, 3 ss. — 33., sodrC bicarbonat., 




Fig. 93. — Probe for applying acetic acid to the turbinated bones. 

3 SS. — 3]'., or better still, Dobell's solution (Appendix, Pre- 
scription 1^0. 1). The first effect of the application is to cause 
considerable swelling of the parts, with closure of the passage. 
This lasts a few hours, or perhaps a day, when there com- 
mences to be discharged shreds of whitish membrane, the ex- 
foliation of the cauterized membrane. This discharge may con- 
tinue for several daj^s, and will result in not only a more patu- 
lous condition of the cavity, but also a marked diminution of 
the excessive secretion. 

I have rarely been disappointed of most excellent results 
by the aid of this remedy, and confidently recommend its use. 
It not only destroys the surface layer of the hypertrophied tis- 
sue, but seems to control and check the morbid activity in the 
deeper layers of the membrane. If too much irritation is 
caused b}^ the application, made as suggested above, the amount 
of acid placed on the probe can be limited by taking the acid 
upon another small probe, and dropping it on the probe to be 
used. In this manner the flattened probe can be charged on 



HTPEETEOPHIC NASAL CATAEEH. 201 

one or the other side, according to the side of the nose to 
be treated. In this manner also the septum remains untouched 
by the acid. 

Actual cautery. — I at one time made considerable trial of 
stout wires, fashioned into different shapes and heated to a red 
heat, for destroying the thickened tissue over the turbinated 
bones anteriorly. The applications were extremely painful ; 
the wires being necessarily small, the heat was rapidly dissi- 
pated, and hence the amount of destruction accomplished was 
limited ; and moreover, from the use of so sluggish a heat, 
probably, the applications seemed to set up too much irritation. 
This method of cauterization cannot be recommended as pos- 
sessing any advantages over others, but rather should be con- 
demned. 

The galvano-cautery. — This instrument is coming into more 
general use every year, and deservedly so, as it possesses many 
and decided advantages over any of the devices alluded to for 
the destruction of the hypertrophic tissue in nasal catarrh. It 
is rapid in its action, its use is not attended with any marked 
degree of pain, it is efficient in destroying the tissue which it 
is desired to remove, and it is in no great degree stimulating, al- 
though, of course, it causes a considerable degree of subsequent 
irritation and swelling of the parts. This soon subsides, how- 
ever, and with it all tendency toward the development of any 
renewed inflammatory action in the deeper tissues of the mem- 
brane. 

In Fig. 96 is shown a set of instruments which I have had 
constructed for my own use to fulfil the requirements of a 
light, easily manipulated handle, and an electrode mounted at 
such an angle as will still further facilitate the ease of manipu- 
lation, and also mounted in such a way as will enable the oper- 
ator to follow by ocular inspection the movements of the heated 
wire. As will be seen, the circuit-closer is immediately under 
the thumb when the instrument is held in the hand, and the 
current can be closed or opened at will. Mounted in the han- 
dle in the cut is shown a slender electrode fitted with a fiat 
blade, and designed for cauterizing the face of the turbinated 
bones. 

Occasionally I use the knife (Fig. 90, a) when the hyper- 
trophied mass anteriorly stands out prominently, making a 
linear incision along its face, and cutting deeply. The effect of 



202 



DISEASES OF THE NASAL CAVIXr. 



this is to produce an incision which, in closing, forms a long 
cicatrix, which contracts to a greater extent than results from 
a superficial cauterization. As will be noticed, the cutting 
blade occupies but one side of the electrode. 

For making applications to the vault of the pharynx, the 
difficult}^ generally met with is in managing the soft palate, 
which lifts itself up, and is in danger of being burned by con- 
tact with the electrode. This may be obviated by tying the 
palate after the manner of Wales. (See page 29.) This, how- 



_0 





Fig. 06. — The authors palvano-cautery instnimPntB. The electrode for makinor application to the 
turbinat&l bones is mounted in the handle : a. knife for making linear incisions on the face of the turbi- 
nated bonus ; b, electrode for the vault of the pharynx ; c, ecraseur. 



ever, consumes time, and is not always agreeable to the 
patient. I have devised the electrode shown in Fig. 96, b, for 
making this application, without the necessity of tying the pal- 
ate. As will be seen, it consists of a spiral wire, mounted at 
the proper curve for reaching the pharyngeal vault ; over this 
there is fitted a hard-rubber hood. When the instrument is 
passed to the point at which it is desired to cauterize, it is 
pressed against the part, and emerges from its hood, when the 
circuit may be closed and the part burned. Before removing 
it the circuit is broken, when it is easily withdrawn. The pal- 



HYPERTROPHIC NASAL CATARRH. 203 

ate, during tlie manipulation, is perfectly protected and saved 
from any injury. 

There is shown also in the plate (Fig. 96, c) a slender double 
canula for use with the ecraseur. The wheel ecraseur is shown, 
not only mounted on the handle, but also separately and in 
front outline. It is so constructed that it can be joined to or 
detached from the handle with perfect facility. This is the 
device of Dr. Shurley, of Detroit, so modified that the wheel 
can be turned by the thumb. 

Fig. 97 shows a very ingenious device of Dr. Lincoln's, of 
New York, for accomplishing the same end. In this instru- 
ment the whole electrode is within a spiral spring, in the end of 
which there is mounted a cup-shaped hard-rubber hood, within 




Fig. 07. — Lincoln's electrode for the vault of the pharynx. 

which lies the platinum cone. Passing the instrument to the 
vault of the pharynx, and pressing the cup upon the parts, the 
cone emerges from its retreat, and again falls into it on the 
release of the pressure. 

The practical working of this instrument is not entirely 
satisfactory in all cases, as the play of the cone in its cup is 
liable to be hampered more or less ; and, moreover, its direc- 
tion is upward, and while reaching the upper portion of the 
glandular mass in the vault, it fails to reach that larger portion 
of the mass which lies on a more vertical plane. 

In using the cautery through the anterior nares, especially 
if the septum is not involved, and it is only desired to cauter- 
ize tlie turbinated bones, the speculum of Dr. Shurley (Fig. 
98) should be used. This instrument has fitted into its inner 



204 



DISEASES OF THE NASAL CAVITY. 




Fig. 98.— Shurley'i 
slide. 



nasal speculum with luovable 



blade a movable ivory slide, wliicli can be passed into tlie cav- 
ity and along the septum, thus completely protecting it from 
the impact of the heated electrode. Of course a different in- 
strument is necessary for each nostril. 

The serious objection to the galvano-cautery lies in its high 

cost, but the excellent re- 
sults that may be obtained 
from its use should induce 
every physician who is call- 
ed on to treat many cases 
of nasal catarrh to have it 
in his power to use it. As 
regards the battery to be 
preferred it is difficult to 
decide. The Dawson bat- 
tery is, perhaps, the most 
simple in its action, and ful- 
ly as reliable as any. The Piffard and Byrne batteries are also 
most excellent instruments. 

By following out the above-described plan of treatment, it 
will be found that most cases of hj^pertrophic catarrh, of even 
very long standing, will be 
overcome. In some cases, how- 
ever, there is met with a con- 
dition which, ns a rule, will 
require a still different meth- 
od of treatment. This con- 
dition consists in an excessive 
hypertrophy of the membrane 
covering the posterior termi- 
nation of the inferior turbi- 
nated bone, resulting in a 
large rounded mass, almost, 
if not entirely, filling the oval 
opening of the posterior nares. 
An excellent example of this 
is shown in Fig. 99. Why this excessive growth of the morbid 
tissue should develop at this place, can only be accounted for 
by the fact that this is the widest part of the nasal passage, 
and hence there is less hindrance to the hypertrophic i^rocess. 
The rhinoscopic examination (see Fig. 99) easily reveals the ex- 




FlG. 99. — Hypertrophy of the mucous membrane 
of the inferior turbinated bones postenorly, from a 
drawing of a case rejjorted by Dr. LefEerts. (From 
Eobinson.) 



HYPERTROPHIC NASAL CATARRH. 



205 



istence of this condition. There will be seen the rounded mass, 
more or less completely filling one or both posterior nares, and 
showing the characteristic grayish-white blanched color, wrink- 
led surface, and seamed or slightly fissured outline of hypertro- 
phic tissue. Springing from the end of the turbinated bone it 
grows outward, downward, and backward, forming 
a sessile tumor projecting toward the septum in- ^ 

ternally, resting on the floor of the nares and soft 
palate below, and protruding somewhat into the 
upper pharjmx posteriorly. Owing to its position 
and shape, it is not feasible to destroy the mass by 
cauterization, or by any of the measures already 
alluded to. By far the most satisfactory method 
of dealing with it is to remove it by a small ecra- 
seur or snare. This w^as first done, as far as I 
know, by Dr. Jarvis of this city, who has devised 
a very ingenious and efficient little instrument for 
the purpose. This is shown in Fig. 100. It con- 
sists of a slender but stout tube, about the size 
of a No. 3 sound, English scale, on the proximal 
end of which there is turned a fine thread about 
two and a half inches long. On this thread there 
plays a round milled nut, which carries before it 
an outer tube two and a half inches long, which 
slides over the threaded portion. The end of the 
outer tube is fitted with two small pins. The wire 
used ma}^ be fine annealed wire, or, better still, 
piano wire. The working is obvious ; the two ends 
of the wire are passed up through the canula and 
fastened to the pins on the proximal end of the 
outer movable tube, leaving a loop at the distal 
end. By turning, now, the milled nut the outer 
tube is carried up and at the same time draws in 
and contracts the loop. 

The a6tion of this little instrument in removing 
these masses leaves nothing to be desired. It 
should be fitted preferably with No. 5 piano wire, as possess- 
ing more elasticity and tensile strength than the annealed wire. 
Owing to its small size, this instrument can be passed through 
a nasal cavity even if it be very greatly encroached upon by 
the hypertrophied membrane of chronic catarrh. In operating, 



Fig. lUO.— Jar- 
vis' wire snare 
ecraseur. 



206 



DISEASES OF THE NASAL CAVITY. 



the snare is prepared with a loop which, on inspection of the 
mass, it is judged will pass over it ; then, first, bending the 
loop 'slishtly outward, it is passed through the cavity until it 
has reached the end of the turbinated bone, wiien the bend 
given to the loop will throw it over the mass (See Fig. 101). 
Exercising now a slight traction on the instrument, if it is 
found to be engaged, a few turns of the milled nut will secure 
it, after which the mass may be cut through at leisure. It is 
best that the operation be done very slowly, consuming even 
a half-hour or an hour after the loop is in place, as by this 
plan it can be accomplished with but slight hemorrhage. If 
there is any difficulty in placing the loop in position, the rhi- 
noscopic mirror should be used to reveal its position and the 
obstacles to its proper adjustment ; these latter can, of course. 




Pio. 101. -Hypertrophy of the lower turbinated bone posteriorly, with Jarvis's tnare in position for 
removing it. from a pathological specimen in the pos=e.ssion of Dr. Jarvis. 

be easily overcome by throwing the wire over the mass with 
the linger passed around the palate. I have repeatedly seen 
masses removed by this instrument quite as large as chest- 
nuts, the relief given being very marked. 

Occasionally there will be found a prominent mass of hyper- 
tropliic tissue at the anterior termination of the lower turbi-. 
nated bone. This may be so great as to more or less completely 
occlude the anterior nares, and, of course, give rise to no little 
discomfort to the patient by the interference with breathing. 
A simple device of Dr. Jarvis enabl-es one to remove this also 
with the ecraseur. The mass is transfixed by a long slender 
needle, mounted in a light handle, and the loop is passed oyer 
the needle, and made to engage the portion of the mass which 
has been transfixed, when it is slowly cut through. I have 



HYPERTROPHIC NASAL CATARRH. 207 

frequently made use of tliis simple device with most satisfac- 
tory results, relieving, oftentimes immediately, a very annoying 
anterior stenosis v^liich had caused no little obstruction. The 
cicatricial contraction which ensues also seems to still more re- 
lieve the stenosis. 

In those cases in which the vault of the pharynx is involved, 
and this region will be found to be diseased in a very large pro- 
portion of cases of nasal catarrh, the plan of procedure will 
depend mainly on the character and extent of the morbid con- 
dition. If there be an excessive hypertrophy of the glands, as 
manifested by the large, rounded, and oftentimes pendulous 
masses developed in this region, active surgical measures will 
be required. These measures will consist in the use of the gal- 
vano-cautery, the forceps, or the curette. My preference is 
very decidedly in favor of the galvano-cautery ; I have used it 
in a number of cases and with excellent results. The method 



Fig. 102.— The author's wire curette for use in glandular hypertrophy at the vault or the pnarynx. 

of using it is with the hooded electrode shown in Fig. 93, I). 
This renders the operation comparatively easy, and does not 
require any preparation, as tying the palate, etc. The applica- 
tion is attended with some pain, but this is but momentary 
and can be relieved immediately by throwing upon the partfe 
some alkaline solution, as DobelFs Solution, Prescription No. 
1, in the Appendix. 

The use of the forceps consists in the seizure, and evulsion 
of the masses, by means of a stout pair of curved forceps. I 
have never used this instrument, but should consider it a 
somewhat harsh procedure. 

Occasionally there will be found a condition at the vault of 
the pharynx, in which the hypertrophy seems to spread broadly 
over the whole region, and to be composed of small rounded 
masses, which do not project to any great extent from their 
bed. In these cases I have occasionally resorted to the use of 
tlie wire curette shown in Fig. 102. This instrument is Thomas' 



208 DISEASES OF THE NASAL CAVITY. 

soft copper wire uterine curette, bent in sucli a manner as to 
adapt it for use in tlie pharyngeal vault. Its use is not espe- 
cially painful, and it serves an excellent purpose in breaking up 
and disorganizing these growths. 

In Fig. 103 is shown a somewhat more elaborate curette, de- 
vised by Mackenzie, in which the loop can be fixed at any de- 
sired angle. The loo]5 also possesses a catting edge, in place of 
the scraping edge of the curette I have been accustomed to use. 

In case the hypertrophy has not developed to any marked 
extent, the use of chemical agents will be resorted to in prefer- 
ence to surgical measures. 

As already suggested, chromic acid seems to afford the best 
results. Its fine acicular crystals also afford an excellent form 
for convenience of application. Nitrate of silver I have occa- 
sionally employed, but I know of no good reason for its use. 




Fig. 1(13. — Mackenzie's curette. — '• At « there is a button by ni' .lui- ' :;,:iil li'l si' ■ in^' ihri.iiigh 

a spiral spring bolts the hinge at b, and thus fi.Kes the cutting loop c at the du.iirud angle."" ^ilaclienzie.) 

Nitric acid should not. as a rule, be applied in the vault, as it 
is difficult to limit its action, and there is a possible danger of 
its reaching parts which it is not desirable to touch. 

As regards the use of spraj^s and douches in this region, it 
is impossible to produce absorption of this hypertrophied tis- 
sue by any means other than destructive agents ; and all 
that can be hoped for by these methods will be the alleviation 
of symptoms. This can undoubtedly be accomplished by the 
spray and douche, and that in a marked degree very often, but 
the relief is only temporar3^ 

To sum up, then, somewhat brietiy, in regard to this question 
of catarrh, we may accejDt the following conclusions. The essen- 
tial morbid condition in chronic nasal catarrh of long standing, 
consists in a h3^pertroph3^ of the mucous membrane lining the 
nasal cavity proper, and the vault of the pharynx ; and the 



HYPEETEOPHIC NASAL CATaREH. 209 

snccessful treatment of the affection lies in the destruction of 
this thickened tissue. Of the resources at present available, 
the galvano-cautery affords the best results, and is equally 
applicable to the nasal cavity proper, and also to the vault 
of the pharynx. In those cases which present extensive en- 
largements at the posterior termination of the inferior turbi- 
nated bone, the galvano-cautery is not available. In these cases 
the mass should be removed, and the best method of doing this 
is by means of Jarvis' snare (Fig. 100). The galvano-cautery 
being an expensive and cumbrous instrument, and not always 
at hand, the use of some one of the chemical agents will become 
necessar}^ Of these, for use in the nasal cavity proper, being 
applied throL\gh the nostrils, I should give preference to acetic 
acid, after this to chromic acid, and last to nitric acid. The 
acetic and nitric acids are neither very applicable to the vault 
of the pharynx ; hence, of the chemical agents for treating this 
region, I should give preference to the chromic acid. Nitrate 
of silver should not be used, as it is in the end more power- 
fully stimulant than destructive. The actual cautery is not 
well borne and not very efficient. The use of the forceps for 
tearing away tissue is an unnecessarily harsh procedure. Sponge- 
tents and steel sounds do not accomplish the desired end. 

In making use of destructive agents in the nasal cavity, it 
is not well to prolong the sittings, or to attempt to do too much 
at one session, nor is it well, as a rale, to repeat the operations 
oftener than once in a week, or, better still, once in two weeks. 
At the time of operation it should be the constant aim of the 
operator to accomplish the treatment with as little irritation 
as possible, and this is measured by the amount of pain given. 

The application of the cautery or caustic should be followed 
as quickly as possible by the application to the burned surface 
of some mild alkaline solution in the form of spray, or by the 
syringe. For this purpose there may be used a solution of 
salt, soda, lime-water, or any bland unirritating fluid. DobelFs 
solution answers the j^urpose excellently well. If these fail to 
relieve the pain, sweet oil or vaseline may be used. Watery 
solutions should, however, be given the preference, as they serve 
to cool the parts and reduce the heat, thereby lessening the 
danger of subsequent mishap. 

The accident most liable to occur after cauterization of the 
nasal cavity is facial erysipelas. When we remember that this 
14 



210 DISEASES OF THE NASAL CAVITY.* 

may occasionally develop from an attack of acute coryza, it is 
easy to understand why it is liable to occur after the use of 
caustics or the cautery in the nose. In my own experience 
it has occurred once as the result of the use of nitrate of silver, 
and in another instance from the use of the galvano-cautery. It 
should be borne in mind, therefore, as one of the accidents that 
may occur. As regards the method of preventing its occur- 
rence, I know of nothing better than the free use of alkaline 
solutions, as above, and the avoidance of too frequent and too 
prolonged sittings. 

It should not be understood that the plan of treatment 
detailed above for the management of the advanced cases of 
hypertrophic catarrh, does away entirel}^ with the use of the 
douche and spray ; on the contrarj^ these methods are un- 
questionably of great value and should always be resorted to 
in connection with the destructive agents. While portions of 
the lining membrane of the nasal cavities are involved in the 
hypertrophic process, other portions are in a condition of 
simple catarrhal inflammation, and hence require the applica- 
tion of astringent remedies. These, therefore, should be re- 
sorted to under the rules given in the earlier portion of the 
section. 

Before closing this branch of the subject it may be well to 
refer to a feature of nasal catarrh, not infrequently made 
use of by irregular practitioners. There are certain remedies 
whose action on the mucous membrane of the nose is power- 
fully stimulant, and the result of their use is to produce a 
condition not unlike a cold in the head, of a most aggravated 
and distressing character. The membrane is irritated and 
painful, the secretions are stimulated to an extremely abnor- 
mal extent, and are poured out in the greatest excess ; there is 
headache, facial neuralgia, etc. This may last a number of 
days, and, as a rule, they are days of great suffering. 

Now, when these symptoms subside, there ensues a period 
of almost entire freedom from all the prominent subjective 
symptoms of catarrh. AVhat has happened is probably as 
follows : under the influence of the stimulating application 
all the normal functions and processes of the membrane take 
on an excessive activity ; the blood-vessels are greatly distend- 
ed, and the secretion of mucus is enormously increased, es- 
pecially in its watery constituents. This discharge pouring 



< 



HYPERTROPHIC NASAL CATARRH. 211 

tliroiigl] the tissues, clears tliem out, all the conduits of the 
membrane are flushed, as it were, hence there is carried off 
a great quantity of worn-out epithelium fi'om the surface of 
the membrane and from the cavities of the glands. The cells, 
also, which have infiltrated the deep layer of the membrane, 
are swept out. The result of it all is that when this activity 
subsides, the membrane is left in a comparatively healthy 
condition as regards functional activity. This condition of 
comparative health may last for weeks ; but sooner or later 
all the old trouble returns in as aggravated a form as before, 
and probably in a worse one. This plan of treatment is not 
a rational one, and results in no permanent benefit to the 
patient ; and yet it is the one on which is based an immense 
number of so-called cures of catarrh. 



CHAPTER XIII. 

CHEONIC NASAL CATAEEH (Continued), 

Atrophic or Dry Catarrh. 

This form of catarrh is one in which, as the result of 
chronic inflammation, the glandular structures of the mem- 
brane are destroyed or their function so far interfered with 
that the membrane fails of the normal supplj^ of mucus by 
which it is kept in a soft, moist, and pliable condition. It will 
be remembered that in the chapter on mucous membranes it 
was stated that the prominent feature of chronic inflammation, 
is a deposition in the deep layer of the structure, of newly de- 
veloped connective and elastic tissue, and other of its normal 
constituents. As a result of this, the glands and follicles be- 
come so crowded and pressed upon, that they undergo atro^^hy, 
or their function becomes greatly interfered with. This may 
occur very early in the course of a chronic inflammation, as the 
result of simple mechanical interference with function, by pres- 
sure on the glands, by the crowding of the new elements ; or it 
may occur in the later stages, by the contraction wliicli takes 
place in the connective tissue as it becomes more firmly oigan- 
ized, encroaching upon and destroying the glands. Hence this 
form of the disease may occur comparativel}'^ early in the yjrog- 
ress of a chronic nasal catarrh ; or it may be a very late develop- 
ment, in wdiich case it becomes a sequela of the hypertrophic 
form of the disease. Its course is very much influenced b}^ the 
surroundings of the patient, the atmosphere which he breathes, 
his occupation and habits of life. Persons living in an abnor- 
mally dry atmosphere, in which the upper air-passages rapidly 
lose their moisture, are liable to develop the dry form of catarrh 
quite early. As a matter of clinical observation, tailors, shoe- 
makers, tobacco-workers, laborers in spice-mills, house-carpen- 
ters, etc., are extremely liable to dry catarrh. It msiy be stated,- 



ATEOPHIC OR DEY CATARRH. 213 

as a rule, that indoor workers are far more liable to tins form 
of the disease than those whose occupation is in the open air. 
Especially is this true of those who work in crowded and badly 
ventilated rooms. Attacks of dry catarrh are very liable to 
occur in those suffering from nasal catarrh, from temporary, 
causes, such as an evening spent in a dusty and crowded 
concert or ball-room, or under any circumstances which in- 
volve the necessity of breathing an abnormally dry atmos- 
phere. 

Those causes which tend to produce this affection during the 
day, are far more active during sleeping hours ; and a single 
night spent in an abnormally dry atmosphere may prove suffi- 
cient to give rise to a dry catarrh, which, though temporary in 
character, occasions no little pain and annoyance. 

Symptoins. — The prominent symptoms of the disease are 
more or less marked pain of a somewhat sharp and tingling 
character, with an excessive irritability of the parts. This 
pain is probably due to pressure on the terminal filaments of 
the sensory nerves. If the anterior nares are affected, the 
sense of smell is somewhat impaired. There is pain extending 
to the forehead, and the disease is marked b}^ the accumula- 
tion in the nasal cavity of thin, dry, closely adherent crusts. 
These are very tenacious and are detached with difficulty. 
They have a grayish color, and consist mainly of mucus and 
muco-pus, discolored by such impurities as the inspired air 
may lodge upon them. In the earlier stages of the disease in 
this locality, the symptoms are not very prominent. There is 
a sense of discomfort, with slight tingling in the nose, and a 
condition of irritability under the influence of changes of tem- 
l)erature of the inspired air ; a breath of cold air drawn 
through the passages, as a rule, being quite painful. There is 
a moderate increase of secretion, which is removed with diffi- 
culty on account of its tendency to dry upon and adhere to 
the parts. As the disease progresses, the symj)toms become 
more marked ; the thin pellicle of dried mucus which charac- 
terized the earlier condition, now becomes a thick crust, which 
adheres with still greater tenacity. The amount of discharge 
is considerable, and yet it loses its moisture very rapidly, and 
even when first secreted is poured out as a thick, viscid fluid. 
As these masses accumulate in the nose, there is a tendency 
to decomposition, wliich gives rise to a peculiar and slightly 



214 DISEASES OF THE NASAL CAVITY. 

offensive odor ; it is not fetid in character, but lias more of a 
musty odor. As the result of the irritation of these crusts, 
superficial erosions ma}^ take place on the mucous membrane, 
which bleed easily to the touch, and under the irritation of the 
mass lying upon them and irritating them, so that there are 
occasionally found small masses of blood in the discharges. 

If the vault of the pharynx is involved, the secretion from 
this part becomes of the same dry tenacious character. These 
masses form in the dome of the pharynx and extend down 
behind the soft palate, between it and the wall of the pharynx ; 
they adhere closely to the parts, and are removed with diffi- 
culty, it being often necessary to seize them and tear them 
off with the forceps. They give rise to a feeling of exceeding 
discomfort in the fauces; there is a sense of a foreign body 
which the sufferer attempts to dislodge by ineffectual efforts 
at swallowing, and the act itself becomes difficult and painful 
from the lack of proper flexibility in the faucial mucous mem- 
brane. There is a feeling of dryness in the throat, with pain 
of a sharp, stinging character. 

Examination. — On examination of the lower pharynx 
there will be seen a peculiar, dry, parchment-like appearance 
of the membrane, with a plug of dry shreddy mucus protrud- 
ing in the median line. The mass is generally discolored by 
the impurities of the inspired air. If now a mirror is placed 
in position to bring into view the upper portion of the pharynx, 
the same condition will be seen. The membrane presents a 
dry and glazed appearance, and is covered by a thick, dirty 
crust Of inspissated mucus, which seems to pile itself in the 
median line, sending out rootlets, as it were, into the crevices 
and fissures between the enlarged glandular masses which lie 
beneath. If this mucous plug is removed and the membrane 
thoroughly moistened, these appearances entirely disappear, 
and there is left behind a mucous membrane, much reddened, 
as the result of the measures resorted to for cleaning, but en- 
tirely healthy in appearance, unless the disease .has resulted 
from the hypertrophic form of catarrh, when there will be found 
in this locality the hypertrophied glandular tissues which char- 
acterizes that form of the disease. The examination of the 
posterior nares shows, ordinarily, veiy little that is character- 
istic of this affection, except in very advanced cases there may 
be brought into view a few of the dry crusts or masses in the 



ATROPHIC OR DRY CATARRH, 215 

upper portion of the cavity, in tlie region of the middle or 
upper turbinated bones. 

As a rule, however, our information in regard to dry 
catarrh is derived from inspection of the anterior nares and 
vault of the pharynx. The examination of the anterior nares 
shows in one or both cavities, and generally in both, the same 
abnormal dryness of the mncous membrane with the accumu- 
lation upon it of thin crusts of inspissated mucus or muco- 
pus, varying with the age and duration of the disease. These 
crusts mainly form in the upper and anterior portion of the 
cavity, on the faces and anterior terminations of the middle 
and lower turbinated bones, and also on a portion of the sep- 
tum. If these parts be thoroughly cleansed, the same is true 
here also that was true with regard to the vault of the pharynx, 
that the mucous membrane will be found to' present a fairly 
healthy appearance, except that it is much congested and red- 
dened as the result of the irritation caused by the means used 
to remove the accretions, except in those cases in which the 
disease has supervened upon the hypertrophic form of catarrh, 
in which case the appearance will remain of that condition. 

Treatment. — The first and most important feature of the 
treatment will be the thorough removal of these crusts and 
masses of dried mucus. The accomplishment of this purpose 
requires somewhat vigorous measures. It is needless to say that 
the ordinary nasal douche is inadequate for the purpose, in that 
the fluid fails to reach the upper portion of the cavity, and also 
that its current is entirely too slow and sluggish to detach the 
masses. Tlie best means we have at our disjDosal is the post-nasal 
syringe shown in Fig. 54. This may be inserted behind the 
palate, or into the anterior nares through the nostril, from which 
points the fluid may be thrown with sufficient force to thorough- 
ly detach and loosen the accumulations, and accomplish the de- 
sired end of cleansing the membrane, and preparing it for the 
subsequent treatment. Occasionally these masses adhere so te- 
naciously that they cannot be removed by means of the syringe. 
Resort may then be had to the use of a slightly curved probe 
wrapped with a pellet of cotton, which may be passed through 
the middle meatus back to the pharjmx and drawn out through 
the lower meatus, thus sweeping through the nares and loosen- 
ing the masses not removed by the syringe. If tliis is not 
sufficient it will be necessary to use a pair of slender forceps 



216 DISEASES OE THE NASAL CAVITY. 

for seizing the masses and extracting tliem. The success of 
these procedures should be made evident by repeated inspec- 
tion of the parts, and when the examination reveals that the 
membrane is thoroughly cleansed it is ready for the next step, 
which is the application of such remedies as will tend to re- 
store its normal secreting function. For this purpose there are 
used various agents which are designated as stimulating appli- 
cations. These are, in the order of preference, sanguinaria, 
galanga, carbolic acid, creosote, salicylic acid, iodine, bromide 
of potash, belladonna, mj^rrh, etc. The efficac}^ of these reme- 
dies lies probably in their irritating qualities. Being applied 
to a membrane, they give rise to a local irritation of the parts, 
which in turn leads to a stimulation of the glandular struc- 
tures, by which a discharge of mucus is excited, and which is 
poured out with more or less profusion. 

The remedies above alluded to may be used either in the 
form of powder, by insufflation, or in solution by means of the 
atomizer. The best results can be secured, however, in dry 
catarrh by the use of powders ; as by this means there is ob- 
tained a more permanent and longer continued action of the 
drug than by solutions, which are washed away more rapidly. 
Sanguinaria is placed first in the remedies above suggested, as 
of this drug I can speak more confidently than of the others, 
having made a larger use of it, and with excellent results. It 
is powerful in its action, and occasionally gives rise to a con- 
siderable degree of pain of a burning, smarting character ; 
hence its use should be undertaken with some little care. 

The pure drug should not be used, but it should be some- 
what reduced, as follows : 

5 . Pulv. sanguinariffi, 

Pulv. m^'rrhse aa 3 j. 

Lvcopodii 3 ij. 

M. 

The amount of the sanguinaria in the above may be in- 
creased or reduced according to the result of its use. Of the 
galanga I have made use only to a limited extent, and can- 
not speak so confidently of its action. In many cases, how- 
ever, it has seemed to act even more favorably than the san- 
guinaria. 



ATROPHIC OR DRY CATARRH. 217 

The galanga may be used pure, or reduced by the addition 
of any of the neutral powders as, 

5. Pulv. galangae, 

Pulv. amyli aa 3 j. 

M. 

B. Pulv. galangPB, 

Pulv. myrrhse, 

Pulv. acacise aa 3 j . 

M. 

The above method may not always be well borne, in which 
case resort may be had to one of the following : 

15 . Acidi salicylic , 3 j. 

Lycopodii ad. 3 ss. 

M. 

I^. Potass, bromidi 3 j. 

Sacch. alb 3 iij. 

M. 

IJ. Pulv. myrrhse, 

Lycopodii aa 3 j. 

M. 

B . Pulv. belladonnse 3 ss. 

Magnesia calc | ss. 

M. 

5 . Sod?e salicylat 3 ss. 

Sodffi bicarb 3 j. 

Pulv. amyli 3 ss. 

M. 

In using solutions, the same drugs ma}^ be used, and of much 
the same strength, or there may be used, 

I^ . Acidi carbolici gr. x. — xxx. 

AqUtC 3 j. 

M. 



218 DISEASES OF THE N^ASAL CAYITY. 

I^ . Creosoti fil. x. — xxx. 

Aqiise 'ij. 

M. 

I^ . Tr. iodini co 3 ss, 

Aquse 3 j. 

M. 

I^ . Potass, bromidi 3 ss. — 3 ij. 

AqucB § j. 

M. 

In using the powders tbey should be thrown behind the 
palate by means of the powder insufflator shown in Fig. 47 ; 
and also, if the anterior nares are affected, through the nos- 
trils. In using solutions the atomizer should be employed as 
throwing in but a very moderate amount of the fluid and at 
the same time accomplishing its thorough distribution. 

At the commencement of the treatment, especially if the case 
be an aggravated one, it will be necessary that the patient be 
seen every day ; as improvement is noticed, however, less fre- 
quent applications will be sufficient. 

It is well, generally, that the patient should aid the efforts 
of the physician by carrying out certain simple measures at his 
own home. This consists in keeping the diseased membrane, 
as far as possible, moistened, by the use of some mild alkaline 
solution, to which there may be added carbolic acid or salicy- 
lic acid. This can be thrown in by the small atomizer, Fig. 63, 
or Richardson's atomizer. Fig. 61, and repeated two or three 
times daily, if necessary. For this purpose there may be used 
one of the following : 

^ . Acidi carbolici gr. v. 

Sod?e biborat 3j. 

Aqua? 3 j. 

M. 

Ijt . Acidi salicylici gi'- vj. 

SodfB bicarb 3 ss. 

Aqu?e 3j. 

M. 



FETID NASAL CATAKEII. 219 

By this means tlie membrane is kept moistened, and the 
tendency to incrustation to an extent is controlled. In addi- 
tion, certain general directions should be given to the patient, 
as to the avoidance of those conditions which have a tendency 
to aggravate his trouble, such as attention to the atmosphere 
which he habitually breathes. If his occupation compels his 
confinement to a close room and a dry atmosphere, some artifi- 
cial means should be provided for charging the air with mois- 
ture. As has been said, there are certain occupations which favor 
this form of catarrh, which in general may be described as those 
in which the atmosphere is either excessively dry, or filled with 
fine particles of dust, such as working in tobacco, at artificial 
flowers, indoor carpentery, etc. The avoidance of these del- 
eterious influences may be secured by proper ventilation of 
working rooms. 



Fetid Nasal Catareh. 

In the atrophic or dry form of catarrh previously described, 
fetor does not usually occur, but its tendency is toward the 
development of a form of disease in which the discharge of 
fetid and offensive masses is the prominent symptom. As 
the result of the destruction of the glandular structures of the 
membrane, there is poured out on its surface a thick, viscid 
mucus Avhich is deficient in its wateiy constituents. This mu- 
cus loses its moisture rapidly by evaporation, and there results 
a thin dry pellicle which adheres closely upon the membrane, 
forming virtually an air-tight shield, which covers the convexit}^ 
of the turbinated bones, and also extends into the sinuosities 
of the cavities. This condition constituting dry catarrh may 
exist for a lengthened period, giving rise merely to the symp- 
toms enumerated in the previous section. The long-continued 
action, however, of this condition, tends to develop a fetid ca- 
tarrh in tlie following manner : A viscid mucus is secreted 
which, losing its moisture, forms a dry pellicle on the sur- 
face of the membrane ; the parts beneath are protected from 
contact with the current of air by this air-tight shield, and 
hence the secretions which are still poured out are not only im- 
prisoned, but also retain their moisture and remain fluid. In 
the eaiiier stages of the affection this adveiililious ])ellicle does 



220 DISEASES OF THE NASAL CAVITY. 

not adhere veiy closel}^ to the parts, but is removed by the 
ordinary effort of blowing the nose, and hence the secretions 
are retained but a brief period. As time elapses, however, and 
the disease assumes the more chronic form, this dried pellicle 
adheres quite closely to the membrane, and, resisting ordinary 
efforts to remove it, may remain in place for days or even 
weeks. This is especially true if the incrustation forms in the 
narrower portion of the cavity, and in the sinuosities beneath 
the turbinated bones. As the result, therefore, of the long reten- 
tion of the secretions, they undergo degeneration, and certain pu- 
trid changes set in. The secretion from beneath going on, the 
pellicle is lifted from the surface of the mucous membrane, and 
there are formed thick incrustations or masses. As the result of 
the retained secretions undergoing degeneration, the mucous 
secretion gradually changes to a muco-purulent discharge, and 
finally there sets in a discharge which is mainly of a purulent 
character, and whose source is largely in the epithelial layer of 
the mucous membrane. This purulent discharge, I think, 
lying in contact with the membrane, serves to reinfect it to a 
degree, and still further aggravates the disease, by exciting a 
more profuse purulent discharge. We have thus an illustra- 
tion of what usually occurs in inflammation of those mucous 
tracts whose walls lie in contact, as in the vagina, or the 
urethra. In acute cataiThal inflammation of these parts, the 
secretions, as a rule, become ]3urulent in character very rapidly, 
this being due probably to the fact that, their walls being in 
contact, the discharges are to an extent imprisoned. In the 
nasal cavity, as long as the secretions have free exit, even if a 
catarrh has existed for years, we never meet with a purulent 
or fetid discharge, this only occurring from imprisoned secre- 
tions in the manner above indicated ; in true oz?ena to be 
described ; and in ulceration from syphilis, etc. 

As already noticed, the result of the establishment of a 
fetid catarrh is, that there are formed inspissated masses in the 
nasal cavity which are detached and voided with great diflS.- 
culty. As the secretion goes on from the surface of the mu- 
cous membrane, the masses are lifted from their bed, and still 
losing their moisture, large crusts are gradually built up from 
below, which mould themselves to portions of the cavit}^, 
and at the same time wedge themselves in its narrower por- 
tions, in such a manner that the sufferer is unable to dislodge 



FETID ISTASAL CATAKRH. 221 

them, and tliej^ may remain in position for days and even weeks. 
Their odor is offensive in the extreme, as the result of this 
long retention, during which time the putrefactive changes 
are constantly going on. They are voided in mass at intervals, 
but more frequently small portions become detached and are 
expelled in the act of blowing the nose, in connection with an 
amount of the purulent discharge which escapes from beneatli 
them, mingled with the healthier mucus which is secreted from 
those portions of the mucous lining which are unaffected. 

Another prominent feature of this form of nasal catarrh 
which is very noticeable consists in a shrinking up or atro- 
phy of the turbinated bones. This may be present in advanced 
cases to such an extent that these bones may almost entirely 
disappear, giving rise to a condition of the nasal cavity in 
which its wide patency, or roominess, as it were, is very strik- 
ing. This is accounted for as follows : At the commencement 
of the morbid process, in atrophic catarrh, there is formed on 
the mucous membrane a thin pellicle which, as the result of 
its loss of moisture, necessarily undergoes contraction. On a 
concave surface this contraction would exert no influence, but 
on a convex surface, as over the turbinated bones, the result 
would be a certain amount of pressure exercised upon the 
parts beneath. This action is not unlike that of a film of collo- 
dion painted over a part, which, as we know, contracts in a 
marked degree as the ether evaporates, and exerts a considera- 
ble amount of pressure even when the part is but slightly con- 
vex. The dry pellicle which forms on the convexities of the 
turbinated bones in the atrophic form of nasal catarrh is not 
unlike a film of dried collodion in appearance, and the analogy 
may be carried still further in the pressure which it exerts on 
the parts beneath, in its contraction. This action continuing 
through months and years, and finally resulting in atrophy of 
the bony tissue, is only another exem]Dlification of what is so 
frequently brought to our notice in other morbid changes 
which occur in the economy, viz., that the long-continued ac- 
tion of an apparently very slight morbid condition may even- 
tually result in structural changes in the system, which are 
surprising to us in that they are by no means commensurate 
with the oftentimes almost trivial exciting cause. 

This form of catarrh is essentially a disease of the nasal 
cavity proper and does not extend to the vault of the pha- 



222 DISEASES OF THE NASAL CAVITY. 

rynx. If tlie explanation given in regard to its method of 
development is the true one, it will be readily understood that 
the pharyngeal vault could not well become involved in the 
same process ; for while a dry catarrh may, and very frequently 
does, develop in that region as the result of structural changes 
within the tissues of the mucous membrane, a fetid catarrh, on 
the other hand, is a secondar}^ process, and results from the ac- 
tion of influences which are mainly from without. And fur- 
thermore, in the pharyngeal vault there is not the same ten- 
dency to the accumulation and retention of secretions, nor would 
the dried pellicle of the atrophic catarrh exert any pressure on 
the concavity of this region, but would rather tend to become 
detached by its contraction. 

Symptoms. — From what has been already stated, the prom- 
inent sj'mptoms of the disease are made apparent. They con- 
sist mainly in the accumulation in the nasal cavity of these 
offensive masses and crusts, and their separation and discharge 
at intervals, together with more or less of a Huid discharge. 
The nasal cavity is not encroached upon, hence nasal respira- 
tion is not obstructed. The breath is extremely offensive, and 
yet the sufferer, as a rule, is not conscious of it. This is par- 
tially due to the fact that the sense of smell is markedly im- 
paired, if not entirely lost, and partially the result of that 
loss of sensitiveness which occurs in any nerve of sensation 
when subjected, for a long-continued period, to the uninter- 
rupted action of any constant imjiression. The general sensi- 
bility of the cavity is also somewliat impaired, though not in a 
marked degree. The especial liability to take cold does not, as 
a rule, exist, nor the susceptibility to changes of temperature 
and the influence of a damp atmosphere which characterizes the 
hypertrophic form of catarrh. The general health is not seri- 
ously impaired, and yet a sufferer from fetid catarrh is not 
usually in a thorough state of health. The offensive atmos- 
phere in which he virtually and necessarily lives cannot but 
exercise something of a deleterious influence. 

Examination. — On inspection of the nasal fossse anteriorly 
in this disease, there will be noticed first the unusual degree of 
roominess of the cavity. The lower, and oftentimes the middle 
turbinated bones will be seen to be markedly atrophied. In ex- 
treme cases these bones will present as mere ridges along the 
outer wall of the fossa. In all cases they will be smaller than 



FETID NASAL CATAERH. 223 

normal, and the space between their convexity and the septum 
will be noticeably wide. Very frequently the pharyngeal wall 
will be brought plainly into view after the secretions have been 
removed. There will also be seen lodged in the upper portion 
of the cavity, greenish-yellow masses or incrustations, adhering 
upon and extending beneath the middle or upper turbinated 
bones, and wedged between these parts and the septum. They 
form in the lower meatus and on the floor of the nares, but the 
sufferer can more easily detach them from this locality by vol- 
untary effort, hence they are not so frequently met with here. 
When noticed in this region they are small incrustations, while 
in the upper portion of the fossae they form large accretions 
which mould themselves to the cavity. They are of a green- 
ish-yellow color, and evidently of a purulent character, in con- 
tradistinction from the grayish color of the inspissated mucus, 
which forms the incrustation in ordinary dry catarrh. An ex- 
amination of the posterior nares will reveal the same appear- 
ances, but in a more limited extent. This disease is essentially 
an affection of the anterior and narrower portions of the nasal 
cavities, and does not extend to the posterior and wider por- 
tion. There will be seen, however, small masses, of a bright 
yellow, or blackish -j'-ellow color, lodged, in a majority of cases, 
on the under side of the middle turbinated bones, and occasion- 
ally on the face and under side of the upper. As seen in this 
manner, the masses have more of a purulent character, and there 
is less of an admixture of particles of dust and other impuri- 
ties, which lodge upon the mass anteriorly. . The vault of the 
pharynx will be found, on inspection, the site of a thick, dry, 
tenacious plug of inspissated mucus ; in other words, in this 
locality there will be found a condition of dry catarrh. As al- 
ready intimated, this region does not become the seat of a puru- 
lent or fetid catarrh, and if the secretion here is noticeably of a 
purulent character, either fluid or inspissated, the source of the 
pus must be sought for in the nasal cavity proper. 

After the nasal passages have been thoroughly cleansed, 
there will be found to exist a fairly healthy lining membrane, 
the only departure from the normal condition being in the 
atrophy of the turbinated bones, resulting in the unusual roomi- 
ness of the passages. In cases of long standing there may be 
found superflcial erosions of the membrane, but these are com- 
paratively rare. 



224 DISEASES OF THE NASAL CAVITY. 

Prognosis. — This affection is usually classed among the in- 
tractable and oftentimes incurable diseases. I regard it as quite 
amenable to treatment, if the measures to be detailed are car- 
ried out faithfully, persistently, and with thoroughness. It is 
not possible to give assurance in every individual case that a 
permanent cure can be accomplished, bnt it is warrantable to 
assure the sufferer that with certainty most of the more offen- 
sive features of the disease can be removed, and that in the 
majority of cases the disease can be permanentl}^ cured. It is 
not safe to venture an opinion as to the length of time which 
will be necessarily consumed in the treatment of these cases ; 
the judgment will be based .on the daration and character of 
the disease, and also on the immediate success attending the 
earlier measures adopted for its relief. 

Treatment. — The first indication for treatment will be the 
removal of the crusts and masses from the cavity. This cannot 
be done by the douche or atomizer, but the crusts should be 
first moistened and softened by syringing into the cavity from 
behind the palate with the post-nasal syringe, the fluid used 
being one of the cleansing solutions given in the Appendix. It 
will be necessary then to detach the masses by means of a slen- 
der probe wrapped with a pellet of cotton. This should not be 
done blindly, but the nasal speculum being inserted, the cavity 
should be illuminated, and the movement of the probe direct- 
ed by ocular inspection. In this manner it will be feasible to' 
thoroughly cleanse the whole of the membrane lining the cavity. 
Occasionally it will be found of advantage to throw the cleans- 
ing solution against the incrustations through the nostril, using 
for the purpose a barrel syringe with a long slender nozzle. 
The success of the cleansing process should be repeatedly veri- 
fied by inspection anteriorly and posteriorly. Wherever it is 
feasible to make xise of sunlight in treating these cases, it is of 
very great assistance, as by its use no portion of the cavity 
need escape inspection. 

After the cavity is thoroughly cleansed, and seen to be so 
by inspection, there should be api^lied, preferably by the ato- 
mizer, one of the following : 

5. Potassffi permanganat gr. x. — xx. 

Aquse 3]- 

M. 



FETID NASAL CATARRH. 235 

I^ . Liq. sodse chlorinatse 3 ss. 

Aquae. | j. 

M. 

]> . Acidi carbolici gr. v. — x. 

Aquae 3 j. 

M. 

B . Acidi salicylici gr. iij. — v, 

Aquffi 3J. 

M. 

Finally there should be applied, by means of the insufflator 
sliown in Fig. 47, the following : 

B. lodoformi, 

Tannin. aa 3 j. 

Lycopodii 3 ij. 

M. 

This should be applied through the nostril, and also thrown 
into the posterior nares from behind the palate. The amount 
of the powder thrown in should be quite limited, the object 
being to deposit a very thin film upon the lining membrane of 
the cavity. 

The plan of treatment outlined above would seem a very 
simple one, and yet its success is entirely dependent on the 
thoroughness with which it is carried out. By careful and 
painstaking attention to the directions above given, the plan 
will prove successful in a large majority of cases ; if on the 
other hand one is content to depend on the efficacy of the douche 
or spray, with some simple disinfecting solution, and without 
any preparatory cleansing, the disease will certainly prove an 
obstinate one to deal with. 

At the commencement of a course of treatment the patient 
should be seen daily ; as improvement is noticed, however, 
these, frequent visits will not be necessary. 

It is well to direct that a patient use at his home some mild 
alkaline and disinfectant solution, as follows : 

H . Acidi carbolic gr. x. — xx. 

Sodae biborat 3 j. 

Aqu?e Oj. 

M. 

15 



226 DISEASES OF THE NASAL CAVITY. 

This may be used with the small atomizer (Fig. 63), or 
better still with the post-nasal tube connected with the David- 
son syringe (Fig. 55). Patients are very easily instructed in 
the management of this douche, and its use is attended with 
excellent results ; its especial value lies in the fact that the 
fluid can be thrown with such force that it reaches the whole 
of the upper region of the nasal cavities, and also detaches 
more of the inspissated masses than the spray apparatus can 
do. The Weber nasal douche is of limited value in this affec- 
tion, as failing to reach the whole of the diseased surfaces, and 
as pouring a very sluggish and indolent stream through the 
cavities. 

Oz^NA. 

Tlie affections already described are very properly designa- 
ted as varieties of nasal catarrh, being diseases of the lining 
membrane of the nasal cavities proper. They have been de- 
scribed as being the result of morbid changes in the mucous 
membrane, which are identical in each form of the disease, 
viz., in an abnormal deposit in the membrane of its normal ele- 
ments, giving rise in one case to what was called a hypertro- 
phic catarrh, in another to atrophic catarrh, and Anally to a 
fetid catarrh. There is still another form of nasal catarrh, 
occasionally met with, characterized by an offensive discharge, 
but the source of the disease is not in the nasal passages, 
but is in the accessory sinuses ; retaining the name of nasal 
catarrh, and conflning it to affections of the nasal mucous 
membrane, we use the term ozsena to designate this disease. 

It has been the custom to call every disease of the nasal 
cavities attended with an offensive discharge and fetid breath, 
ozsena. The name is derived from the Greek word, o^aivM, to 
stink, and is used somewhat carelessly. There are a number 
of diseases of the nose which are attended with an offensive 
discharge, as in addition to the one already described as fetid 
catarrh, this symptom is prominent in syphilis, ulceration 
from the presence of foreign bodies, scrofula, etc. 

The form of disease to which the name ozsena should be 
restricted, is that which we find attended with the discharge 
of foul and offensive crusts and masses from the nose, of a 
fetid odor, and in which the most careful examination fails 



oz^NA. 227 

to reveal the source of the disease in the nasal mucous mem- 
brane. The disease is not in the nasal cavity proper, although 
the prominent symptoms are manifested therein. Dr. Carl 
Michel, of Cologne, as far as I know, first called attention to 
the fact, that in these cases the source of the trouble could be 
traced to the accessory cavities, and my own observations lead 
me to adopt this view as the true one. In simple ozgena, then, 
the real disease consists in a catarrhal inflammation of the 
mucous membrane lining one of the accessory cavities. These 
are the sphenoidal and frontal sinuses and the antrum of 
Highmore. As a consequence of their position, size, and 
shape, and being almost completely closed cavities, it is easy 
to understand how a simple inflammation of their lining mem- 
brane will very rapidly degenerate into one of the morbid 
conditions characterized by a purulent discharge, the secre- 
tions being retained, soon undergoing decomposition. As the 
result of the accumulation of these morbid products in the 
accessory cavity, it becomes distended, and the discharge, 
now of an offensive character and with a fetid odor, overflows 
and escapes from its oriflce into the nasal cavity, where it 
diffuses itself over the mucous membrane, and drying, forms 
a thin greenish-yellow, closely adherent pellicle. 

As more of the discharge is poured into the nares, it piles 
up, as it were, and forms thick masses or crusts. These crusts 
adhere very closely to the parts, and the sufferer finds it ex- 
tremely difficult to detach them. As the result of the local- 
ized irritation due to the presence of these masses, superficial 
erosions of the mucous membrane may occur, which, bleeding 
easily, serve to discolor the crusts with blood. 

The prominent symptom of ozsena is the offensive dis- 
charge from the nose. Tliis may be very profuse in amount, 
consisting in the daily discharge of large masses of inspissated 
muco-pus, mixed with blood and such impurities as may be 
lodged upon them from the inspired air; attended also with 
more or less fluid discharge of a muco-purulent character. The 
Ijreath also is very offensive, from the fact that it necessarily 
]iasses over the decomposing and fetid masses, and becomes 
impregnated with the ill-smelling emanations which arise from 
them. This fetid breath is often so penetrating and nauseous 
as to render the near presence of the sufferer not only unpleas- 
ant, but almost unendurable. The odor, however, of simple 



228 DISEASES OF THE NASAL CAVITY. 

ozgena, is not so offensive as a rule, as that of syphilitic disease 
of the nose. 

The causes of oza^na cannot be laid down with any great 
degree of certainty. It may occur as the result of a state of ill 
health from any cause, and perhaps does so occur with more 
frequency than in fair health, although it is frequently met 
with in persons of sound constitution and robust physique. 
Where w^e meet with ozsena, however, in persons whose gen- 
eral health is impaired, we will often find that at the com- 
mencement of the disease the condition of the patient was one 
of robust Ileal th, and that this has become impaired by the dis- 
ease itself. This commences as a purely local affection, and 
remains a local affection ; but the fetid odor which acts to poi- 
son every breath of inspired air, compels the sufferer to live 
virtually in an impure atmosphere which cannot but have a 
deleterious influence on the best of constitutions. A frequent 
source of ozsena is disease of the antrum of Highmore, caused 
in the majority of cases, b}^ carious teeth whose roots project 
into the floor of the cavity. Occasionally it may, in this local- 
ity, give rise to neuralgic i^ains referable to the side involved, 
but this is comparatively rare, not only with reference to the 
antrum, but to all the cavities ; the prominent symptoms being 
the offensive discharges and tlie impaired health resulting there- 
from. As regards the disease having its origin in other cavities 
we can simply say that it is generally due to an acute coryza 
extending to the mucous membrane in these localities. While 
the acute process subsides in the nasal cavities proper, in the 
accessory cavities it lapses into a chronic inflammation, and 
finally, on account of its surroundings, takes on a purulent 
cliaracter. 

The disease essentially belongs to the anterior nasal cavity, 
as it is here that the symptoms manifest themselves, that the 
morbid conditions are seen on which the diagnosis is based, 
and to these parts, mainly, that the efforts of treatment are 
directed. The pharynx is not involved in the affection to any 
extent, and an inspection by the rhinoscopic mirror reveals but 
little of the morbid condition. 

Examination. — An inspection of the parts through the nos- 
tril will bring into view the lower and middle turbinated bones, 
and a large part of the septum. These will be found coated 
almost completely by a thin greenish-yellow, closely adherent 



oz^KA. 229 

pellicle wliicli seems to fit itself to the whole lining of the cav- 
ity as far as seen. In the upper and back portion of the cavitj^- 
there may be seen a thick, heavy mass of inspissated muco-pns 
clinging about the orifice of the sphenoidal sinus. Or again, 
there may be brought into view a mass clinging near the 023en- 
ing into the antrum. 

The nasal cavity being cleansed it will be seen that its mu- 
cous lining is quite healthy in appearance, except that it is some- 
what congested as the result of the measures used to cleanse 
it. It is often said tliat the morbid condition in ozsena is one 
of ulceration. This is not true, for the most careful inspection 
fails to reveal it. There may be slight erosions of the mem- 
brane as the result of the irritation of the dried masses of pus, 
etc., adhering to it. Genuine ulceration, however, does not oc- 
cur, and by ulceration, it should be stated, is only meant a 
solution of continuity, with progressive loss of tissue. Ulcera- 
tive action rarely takes place, except as the result of some pro- 
found dyscrasia, or blood condition, as in syphilis, tuberculosis, 
scrofula, etc. Another condition that will be prominently no- 
ticeable on inspection is the extreme degree of roominess of the 
nasal cavity. This is due to a shrinking of the turbinated bones. 
This is to be accounted for in a manner similar to that given in 
connection with the same appearances in fetid catarrh. The 
pus being poured into the nasal cavity and diffusing itself over 
the turbinated bones, loses its moisture rapidly, and in drying 
undergoes contraction. The thin, dry pellicle thus formed, ex- 
ercises pressure on the parts beneath with the result of causing 
their atrophy. As the result of this the cavity is noticeably 
capacious, so much so that the pharyngeal wall can often be 
seen by inspection through the anterior nares. 

In many cases the orifices of the accessory cavities, which 
may be diseased, can be brought into view after cleansing the 
nasal cavity, plugged with a mass of inspissated pus standing 
out prominently in its bright j^ellow color, as contrasted wit4i 
the red membrane around it. 

Treatment. — The first indication for treatment is the cleans- 
ing of the parts. This may be accomplished by means of Do- 
bell's solution (see Appendix), used with the post-nasal syringe 
(Fig. 54). If this- fails to detach the adherent crusts, a probe, 
wrap])ed with cotton, or the slender forceps, may be used to 
detach the pellicles and masses. This procedure should be 



230 DISEASES OF THE NASAL CAVITY. 

accomplished with a great deal of care, and its success veri- 
fied by frequent inspection of the parts. All the offensive 
masses should be removed and the cavity thoroughly cleansed. 
The especial solution used is not of so much importance as the 
thoroughness with which it is used. 

If now the orifice of the diseased accessory cavity can be 
brought into view, this should be cleansed and opened as far 
as possible by such means as will easily suggest themselves, as 
the use of a slender probe, with a pellet of cotton twisted upon 
its extremity, and as far as possible the cavity itself reached 
for cleansing. When this has been accomplished a disinfecting 
solution should be thrown into it, in the form of the spra3^. 
This can only be accomplished by spraying into the nasal cav- 
ity proper, as by this method some of the atomized fluid which 
fills the whole nares will make its way into the diseased cavity. 
For this purpose there may be used permanganate of potash, 
creosote, or salicylic acid of the strength of from five to ten 
grains to the ounce. Following this there should be injected, 
by means of the powder-insufflator, Fig. 47, a powder composed 
of equal parts of iodoform and ]3'Copodium. the latter being 
added to give lightness to the mass. This should be thrown 
not only against the orifice of the diseased cavity, but distri- 
buted very freely over the membrane of the neighboring parts. 
This treatment should be followed up pretty actively, at first, 
daily applications being often required, and the vigor of the 
treatment only relaxed as improvement is noticed. The im- 
portant features in the management of a case of ozsena are : the 
recognition of the source of the disease, and the use of a cer- 
tain amount of skill and deftness in reaching it for purposes of 
treatment. Keeping these points in view and accomplishing 
these ends the most obstinate case of ozpena will often yield 
satisfactorih^ to treatment, and if not entirely cured it may be 
held under control, and its more distressing symptoms kept in 
check. 



CHAPTER XIV. 

SYPHILIS OF THE NOSE. 

The manifestations of syphilis in the nasal cavity belong 
essentially to the tertiary period, the earlier lesions rarely if 
ever being met with in this region. 

Sypliilltic coryza. — This occasionally occurs in the early 
stages of syphilis, but presents no features which enable us to 
recognize it as due to the specific virus, and the diagnosis de- 
pends entirely on the clinical history of the case. It occurs 
from six weeks to three months after the primary sore, and 
generally in connection with a roseola. It subsides readily under 
the use of constitutional remedies, and, as a rule, requires no 
local treatment. If, however, it should prove obstinate or per- 
sistent, resort may be had to the same methods of treatment 
which govern the management of a case of simple coryza. 

Mucous patches. — It has been asserted by writers that mu- 
cous patches may occur about the margins of the nostrils, as 
they do about the orifices of other mucous tracts of the body. 
I have never been able to verify this assertion, and am confi- 
dent that if this manifestation of syphilis does occur in the 
nose, it is an exceedingly rare event. When met with it would 
present the same appearances and require the same treatment 
as mucous patches in any other part. 

Syphilitic Oz^na oe Syphilitic Ulceeation in the Nose. 

Covering the period of from five to fifteen years after the 
primary sore, we have a series of deep-seated lesions due to the 
syphilitic poison, which we are accustomed to call tertiary mani- 
festations. This is the period in whicli the nasal cavity is most 
liable to become diseased, and wIkmi this happens we have 
manifested certain grave and destructive forms of ulceration, 



232 DISEASES OF THE NASAL CAVITY. 

which j)ursning a somewhat rapid course lead to more or less ex- 
tensive destruction of tissue, involving the cartilages and bones 
of the organ to such an extent as often to cause permanent and 
unsightly deformities. The progress of the disease is character- 
ized by the discharge of masses of pus, blood, and necrotic 
tissue, which become the source of a most offensive and pene- 
trating stencil. This disease is often confounded with simple 
ozsena, although the two affections are entirely distinct patho- 
logically and in their clinical characteristics. A better usage, 
perhaps, would suggest that the name ozaena be entirely con- 
fined to the idiopathic disease, while this affection be desig- 
nated as syphilis of the nose. Out of deference, however, to 
long-established custom the name is retained. 

We meet with two forms of ulceration in syphilis of the 
nose : a superficial ulcer and a deep ulcer. Of these the latter 
is by far the most frequent, the superficial variety occurring 
somewhat rarely. 

Tlie sujyerficial ulcer. — In the superficial form we meet 
with an ulcerative process commencing apparently on the sur- 
face of the mucous membrane, and which erodes the tissue by 
a somewhat slow process of destruction, spreading both latei'- 
ally and also deeply. Its borders are moderately well defined, 
and the mucous membrane surrounding it perfectly normal in 
appearance, there being no areola of redness. The edges of the 
ulcer are neither sharply cut nor depressed ; the .surface, how- 
ever, is somewhat depressed at its centre, while its borders are 
flush with the surrounding membrane. Its surface is covered 
with a coating of thick, stringy, grayish-yellow muco-pus. If 
this is removed the cleansed surface will show a grayish-pink 
color ; it is feebly sensitive to the touch, but bleeds easily. In 
the majority of cases this form of ulceration is found on the 
cartilage of the septum, although it may extend to the bony 
septum, resulting in more or less complete destruction of the 
part. 

TTte deep ulcer. — The other form of tertiary ulcer which is 
met with in the nasal cavity, in a very large majority of cases 
if Tiot in all cases, is due to the deposit in the deep layers of 
the mucous membrane, of gummata, which becoming softened 
and breaking down, develop rapidly into ulcerative action. 
This gives rise to the deeper form of ulceration, which presents 
certain characteristic appearances. It is a deep, excavating 



SYPHILITIC OZ.'ENA OK SYPHILITIC ULCERATION. 233 

ulcer, with ragged overhanging edges ; the mucous membrane 
surrounding it is reddened and darkly congested ; the surface 
of the ulcer is covered with a bright yellow pus, mingled with 
more or less of blackened necrotic tissue, which results from 
the destructive process. This form of ulceration is met with 
generally on the turbinated bones, and extending deeply and 
laterally leads very soon to the destruction of the mucous mem- 
brane and j)eriosteum, with resulting necrosis of the bone. A 
direct view of the ulcerative surface is not, as a rule, easily ob- 
tained, but the ragged, puffy appearance of the mucous mem- 
brane, with the red areola about the borders of the ulcer, and 
the history of the case, will always enable the physician to 
form a pretty accurate opinion as to what condition exists. In 
most cases, probably, the diagnosis can only be determined with 
accuracy by a thorough investigation with the probe, which 
will reveal very early in the progress of the disease the exis- 
tence of denuded, if not necrosed bone ; for, as has been sug- 
gested, an accurate diagnosis in disease of the nose, character- 
ized by fetid or oiTensive discharges, can only be attained by a 
thorough exploration of the cavity by means of the probe, in 
addition to the ordinary inspection. The existence of these 
two forms of ulceration is mainly a matter of clinical observa- 
tion, otherwise their significance and results are much the same, 
as well as the symptoms to which they give rise. There is 
always an extreme!}^ offensive discharge, with an intolerable 
odor of decomposing pus and dead bone, together wdth a ten- 
dency to the formation of crusts or masses of dried pus, blood, 
and decaying tissue, which adhering closely to the ulcerated 
surface are only removed by violent efforts of blowing the nose, 
or by dragging them down with the finger or any improvised 
implement, which the sufferer may resort to for detaching 
them. When dislodged and voided their odor and. appearance 
are unspeakably nauseating. As the disease progresses, and 
more extensive portions of the nasal cavity are involved in the 
destructive process, these crusts are formed in larger masses 
and in greater quantities, so that it becomes impossible for the 
sufferer to get rid of them, and he is only relieved at the hand 
of the physician, who digs them out with the probe and forceps, 
but only to be renewed again in the course of a few hours. 

As a consequence of the morbid process, the natural sup- 
ports of the contour of the nose are destroyed, and there re- 



234 DISEASES OF THE NASAL CAVITY. 

suits the familiar misshapen nose which occurs from necrosis 
of its bones. If the cartilaginous septum is destroyed, the 
lower portion of the nose is flattened. If the nasal bones are 
involved, the bridge of the nose sinks to the level of the cheek, 
while the tip projects like a rounded knob. If necrosis of the 
turbinated bone occurs, and it extends to the superior maxil- 
lary, there is liable to occur a swelling at the angle of the nose 
and cheek, producing on that side the appearances of frog face. 
The floor of the nares is often involved, and the process may 
go on to the extent of producing more or less complete de- 
struction of the hard palate, resulting in an abnormal opening 
between the nose and mouth, giving rise to serious interference 
with swallowing and impairment of the voice. The destruc- 
tive process seems to limit itself to the bony and cartilaginous 
structures of the nasal cavity, and does not, as a rule, extend to 
the soft palate, the septum ala3 narium, or the cutaneous sur- 
faces, the external deformities being conflned to misshapen 
contour of the nose, resulting from destruction of its supports. 

Diagnosis. — Syphilis of the nose is often confounded with 
fetid catarrh and ozjena, the other forms of disease of the 
nose which give rise to offensive odor and discharge. The 
diagnosis is comparatively easy if a thorough and satisfactory 
ocular inspection is obtained of the cavity, and is based on the 
examination through the anterior nares which brings into view 
the parts mainly involved in the disease. 

Examination. — On flrst inspection in either of the different 
forms above described, the appearances are very much alike. 
There is simply brought into view one or both cavities filled 
with dry, offensive looking crusts or fetid masses, which cover 
and conceal the condition of the parts beneath. If, however, by 
one of the metliods above described, these be removed and the 
cavity thoroughly cleansed, an examination will reveal, in 
ozpena and fetid catarrh, that the mucous membrane and walls 
of the nares are intact, while in sj^philis there will be brought 
into view either ulcerations on the septum or turbinated bones, 
or more or less destruction resulting from necrosis. Keeping 
in view the fact that ulcerations never occur except as the 
result of some blood disease, and that the diseases which may 
produce it are syphilis, scrofula, tuberculosis, cancer, and the 
exanthemata ; and furthermore, remembering that, if these 
ulcerations are due, not to syphilis but to one of the other 



SYPHILITIC OZ^NA OE SYPHILITIC ULCERATIOIN^. 235 

affections, other symptoms cliaracteristic of the special disease 
will be well marked, the diagnosis becomes comparatively 
simple. In other words, if we meet with a case of destructive 
ulceration or necrosis in the nose in a patient not showing well- 
marked evidences of impaired health due to scrofula, etc., we 
may with almost absolute certainty say that the disease is 
syphilis. This is true, often, even if the previous history of 
the case is not perfectly clear as regards the primar}^ sore 
and subsequent specihc manifestations. In a number of cases 
which have come within my own observation, the disease has 
developed in the nose after a period of time from ten to twenty 
years, subsequent to the primary lesion, and during which time 
there had been no manifestation of the disease. Remember- 
ing then how comparatively trifling a sore the primary lesion 
may be, and how liable it is to be overlooked, the possibility 
of tertiary syphilis occurring in the nose, without any*satisfac- 
tory history of syphilis preceding it, should be borne in mind. 

Treatment. — The proper management of syphilitic disease 
of the nose involves both general and local treatment, the 
former being alwa^^s essential in controlling the disease, and 
the latter of the utmost importance as limiting its destructive 
ravages and expediting a cure. In my own experience, mer- 
cury is of very limited value, in syphilis of the nose, as con- 
trolling and influencing the ulcerative process. The adminis- 
tration of the iodide of potash is, how^ever, attended with most 
satisfactory and often even brilliant results. This should be 
given from the onset in full doses, and the amount gradually 
increased until a dose is reached, b}^ the administration of 
which very decided improvement is noticed. This should be 
maintained until the desired end is obtained, unless contra- 
indicated by the occurrence of the eruption, coryza, or other 
symptom of iodism. The plan I usually pursue is as follows : 
(•ommencing with fifteen grains three times daily, three grains 
is added to the amount each day until either decided improve- 
ment is noticed or symptoms of iodism produced. 

In addition to constitutional remedies, active local treat- 
ment should be resorted to in order to control the destructive 
])rogress of the disease, to correct as far as possible the offen- 
sive odor, to limit the secretion, and to remove dead bone, 
which acts as a source of irritation and encourages ulceration, 
or rather interferes with reparative processes. The first step 



236 DISEASES OF THE NASAL CAVITY. 

should be the thorough removal of all the masses and crusts 
which cover the diseased part. This should be done by means 
of the post-nasal syringe discharged behind the palate or 
through the anterior nares, with the use of one of the cleans- 
ing solutions given in the Appendix. If the syringe does not 
serve to cleanse the part, the forceps or probe should be re- 
sorted to. If now there is found simple ulceration, without 
necrosis, the surface of the ulcer should be covered with iodo- 
form. This at the commencement of treatment should be done 
as often as possible, certainly two or three times each week, if 
not every day. But as the disease commences to yield to 
treatment, an improvement being noted, less close attention 
will be sufficient. Tlie second end to be accomplished in the 
local treatment is the removal of the offensive secretions and 
the correction of the fetor which not only renders the sufferer's 
presence- offensive to those about him, but also poisons the 
atmosphere in which he himself lives and breathes. This is to 
an extent accomplished by the cleansing process, but in addi- 
tion to this there should be used some disinfectant as follows : 
carbolic acid, gr. v.— ^ j., creosote, mv.— I J., liquor sodas chlor- 
inatfle, 3 j.— ! j., permanganate of potash, gr. xx.— 3 j. These 
may be used with the post-nasal syringe in front or behind, 
but better still with the atomizer, as by this means they pene- 
trate the whole of the nasal cavity and reach portions not so 
liable to be medicated when the syringe alone is used. In 
addition to this at the hands of the physician, it is well that 
the patient also should have some means of treating his dis- 
. ease at home. This may be done as suggested with reference 
to nasal catarrh, and should consist in the use, night and morn- 
ing, of a solution of carbolic acid or permanganate of potash, 
or liquor sodse chlorinatse, by means of the small atomizer, or 
by the nasal douche. In this disease the nasal douche is of 
undoubted value, as the diseased condition is, as a rule, in that 
portion of the cavity which is reached by the fluid used in the 
douche. The only difficulty in its use, however, lies in the 
fact that the diseased surface is ordinarily covered by dried 
crusts, and that these are bathed by the fluid, rather than the 
disease itself. This may be obviated to an extent by directing 
the patient as far as he is able by voluntary effort to expel 
the masses before using the douche. This plan for disinfecting 
is of value not only in the ulcerative stage, but in necrosis as 



SYPHILITIC OZ^]NA OR SYPHILITIC ULCERATION. 237 

well. If necrosis exists, the dead bone should be gotten rid of 
as soon as possible ; this may be accomplished by any of the 
simple means which are familiar to every physician, and under 
the rules which govern the management of necrosis when met 
with in any part of the body. If the extent of necrosis is lim- 
ited, the measures already devised will be sufficient to arrest 
its further progress, and the superficial laminae gradaally giv- 
ing way, the healthy membrane will close over the part and 
the cure be accomplished. If the necrosis involves the septum, 
and perforation has occurred, the ragged edges of the dead 
bone should be cut away or ground off, in order to allow the 
membrane of either side to unite with its fellow and form a 
healthy margin to the new opening. If the turbinated bone is 
involved, it will oftentimes become necessary that the whole 
bone should be removed. Dr. Goodwillie, of this city, has 
reported very excellent results in the management of this dis- 
ease, by the use of the dental engine, which enables him to 
reach with ease and precision through the nostril any dead 
bone that may exist, and to grind it off by operating through 
the same entrance. The duration of the disease can be greatly 
curtailed by the removal of dead bone wherever found, and 
this should be done in all cases where it is feasible. If the 
cartilaginous septum is involved, it may be punched out or 
cut with a strong knife. The after rules for the management 
of this affection consist in the administration of mercury in 
small doses, over a period of from twelve to eighteen months. 
We probably possess no better remedy than the bichloride of 
mercury, and after the disease in the nose has subsided, this 
should be given. If the drug acts on the bowels too freely, 
minute doses of opium may be combined with it. 



(CHAPTER XV. 

SURGICAL AFFECTIONS OF THE NOSE. 
Tumors of the Nasal Cavity. 

Thp: tumors that occur in the nasal cavity are myxomata or 
gelatinous polypi, fibromata or fibrous polypi, adenomata or 
adenoid tumors, and malignant tumors. In addition to these 
we occasionally meet with small warty growths about the nos- 
trils. The discussion of malignant growths of the nose belongs 
more properly to works on general surgery and the subject will 
be omitted here, in that they present no especial features, when 
growing in the nose, different from those whicli are manifested 
in any other portion of the body. AVarty growths are fre- 
quently seen, especially in children, just within the nostril at the 
muco-cutaneous junction. They present the same appearances 
as when met with on the skin or other portions of the body. 
Their main importance is in the. tendency in children to pick at 
them and irritate them until bleeding is excited which may be- 
come serious in extent. They should be removed by the scis- 
sors or any of the ordinary methods, and their base touched 
with nitric acid. Adenoid growths or glandular hypertrophy 
have already been referred to in the article on the hypertro- 
phic form of nasal catarrh, and sufficiently noticed. But two 
forms of new -growths, the gelatinous polypus and fibrous tu- 
mors, remain for consideration. 

Myxomata or Gelatinous Polypi. — The gelatinous poly- 
pus, or, as it is sometimes designated, the nasal polyp, is the 
most common of all tumors whicli have their seat in the nasal 
cavity. Taking their origin in some small point of localized in- 
fianimation, and probably in one of the minute glands of the 
mucous membrane, they grow with more or less rapidity until 
they project into the cavity, and by their own weight sink 
down toward its floor, becoming somewhat elongated and pear- 




TUMOES OF THE NASAL CAVITY. 239 

shaped, their attachment to the part from which they sprung 
being maintained by a narrow portion called the pedicle. (See 
Fig. 104.) As they increase in size they mould themselves to 
the cavity in which they grow. In the majority of cases their 
attachment is to the middle turbi- 
nated bone, about midway of the 
passage. They rarely, if ever, spring 
from the septum or floor of the nares. 
As a rule they occur in groups of from 
three or four to eight or ten, and are 
rarely confined to one cavity. The}' 
are soft, yielding, and semi-elastic to 
the touch. If a probe is pressed 
against them they are easily indent- 
ed, their contour being restored some- rio io4 -Oroiatmous p ijpi'-pnngnig 

, - .11 mi c from the miudle turbinated bone 

what sluggishly. They are or a gray- 
ish color, with a glistening surface, and have something of the 
appearance of a mass of thick mucus. They are composed 
mainly of loose fibres of connective tissue, with some glandular 
tissue and a few epithelial cells, and embrace within their 
meshes a large amount of mucin which is their principal con- 
stituent. 

The prominent symptoms of their existence are : obstruction 
of tlie nose more or less complete, according to their size and 
number ; the discharge of a clear watery fluid, and their pecu- 
liar action under atmospheric changes by which they absorb 
moisture and swell up during damp weather. This hygro- 
scopic character of the gelatinous polypus is due probably 
to endosmotic action. The voice is affected simply in the nasal 
stenosis which they cause, which robs it of its normal nasal 
tone. The discharge is somewhat irritating in character, so 
much so that the margins of the nostrils are frequently red- 
dened and inflamed by its local action. The conjunctiva also 
is liable to reflex irritation by wliicli there is often marked con- 
gestion, with an excessive secretion of tears. The appearance 
of the patient is often markedly suggestive of one suffering 
from a cold in the head. There is the same peculiar vacancy of 
expression, with suffusion of the eyes and profuse discharge 
from the nostril. The nasal membrane is extremely sensitive, 
and sneezing is a prominent symptom of the affection, occurring 
as it does in frequent and often violent and prolonged attacks. 



240 DISEASES OF THE NASAL CAVITY. 

The diagnosis is quite simple, the group of subjective symp- 
toms to which the existence of the gelatinous polypus gives rise 
being peculiarly and pointedly suggestive of that affection. In 
addition to this an inspection through the nostril will readily 
bring into view the tumor, more or less completely filling the 
nasal cavit}^, and wiiich will be recognized by its grayish color, 
moist, glistening appearance, and semi-elasticity to the touch, 
together with its movability, for if it be pressed backward by 
the probe it will be found to move quite freely, showing it to 
be attached by a pedicle rather than by a broad base, to the 
parts beneath. 

Treatment.— 1^\\Q tendency of these tumors is almost inva- 
riably to recur after removal. The explanation of this is that, 
undoubtedly, in many cases the whole tumor with its attach- 
ment is not removed, but that sufiicient of the polyp remains 
as a nucleus from which a new crop may develop in, the same 
manner as before. The proper management then of these polypi 
consists not only in the removal of the tumors, but also in the 
complete destruction or ablation of their attachments or the re- 
moval of the root, as it is sometimes called. 

There are three methods of treating gelatinous polypi which 
may be alluded to : by injection, evulsion by forceps, and re- 
moval by the snare. It is claimed that by throwing into the 
mass of the polyp a few drops of glacial acetic acid, by means 
of the hypodermic syringe, that the tumor will shrivel up and 
drop out. This procedure is extremely attractive by its sim- 
plicity, but unfortunately it does not accomplish the purpose. 
I have never succeeded in accomplishing, by this plan, what is 
claimed for it. Furthermore, it is doubtful if by this proced- 
ure the whole mass, together with its attachments, can be de- 
stroyed. Hence, even if the bulk of the tumor were destroyed, 
it would certainly recur again. 

From time immemorial it has been the practice to remove 
nasal polypi by means of the forceps. The plan recommended 
is to pass the forceps between the tumor and the turbinated 
bone, and to seize the pedicle, and twist or tear it from its attach- 
ment. The manipulation of the instrument is guided mainly 
by the sense of touch, as it is rarely, if ever, possible to bring 
into view the pedicle of a polyp. It is also borne in mind, to 
aid in the manipulation, that in the very large proportion of 
cases the attachment is to the middle turbinated bone. The 



TUMORS or THE NASAL CAVITY. 241 

first attempt to seize a polyp by means of the forceps, neces- 
sarily excites a considerable hemorrhage from the mucous 
membrane, which serves to render still more obscure the ma- 
nipulation. The operation, therefore, is very much in the dark. 
It is taught, that by careful manipulation the operator will be 
enabled to feel his way, as it were, by means of the instrument, 
and that he can recognize the peculiar, soft tissue of the polyp 
when he has seized it within the bite of his instrument. The 
movement of the forceps is necessarily much hampered in the 
narrow passage of the nose, and cramped somewhat, hence it is 
very doubtful if this recognition is possible. The evulsion of a 
polyp then becomes simply a blind groping in the sensitive 
nasal cavity, with a harsh, rude instrument, in which there may 
be seized and torn away the polypus, its. pedicle, the mucous 
membrane, or even the turbinated bone. The operation is ex- 
tremely painful, and is attended with excessive hemorrhage. 
It may succeed in removing the entire tumor with its attach- 




Fig. 105.— The ordinary duck-bill polypus forceps. 

ments, or it may leave portions. Certainly at the time, on ac- 
count of the hemorrhage and the bruising of the parts, it is 
impossible to know how successful the manipulation has 
been. In view then of the fact that we have a much better re- 
sort in the use of the snare, for the removal of gelatinous 
polypi, the operation of evulsion by forceps should be con- 
demned as unsurgical, and often cruel in the excessive and un- 
necessary pain caused, and brutal in the rough usage to which 
tlie healthy tissues are subjected. 

There may be cases occasionally in which it becomes neces- 
sary to resort to the use of the forceps. Fig, 105 shows the or- 
dinary duck-bill polypus forceps. The objection to this instru- 
ment lies in its having a broad tlat blade, whei-eas it is intended 
to be inserted into the narrow vertical fissure between the polyp 
:ind tlie outer wall of the nasal cavity. In addition to this, the 
bite of the instrument comprises a ver}^ small portion of the 
blade. Fig. 106 shows an instrument constructed on the proper 
16 



242 DISEASES OF THE NASAL CAVITY. 

principle. The blades are long, slender, and tapering ; tliey are 
narrow in their transverse diameter, while the}^ are made strong 
by being reinforced in their vertical thickness. The toothed 
bite of the blade comprises nearly its entire length beyond the 
joint. As will be perceived, on account of its shape, the for- 
mer instrument can only be passed into the cavity by forcing 
its way between the tumor and the turbinated bone, while the 
latter can be inserted with comparative facility. 

The use of the snare is unquestionablj^ the least painful, 
the easiest, and the most thoroughly surgical procedure we 
possess for removing nasal polypi. Of the various instruments 
of this class. Dr. Jarvis' instrument, Fig. 100, is the simplest 
and most efficient. It is so much superior to any other device 
within m}^ knowledge that further allusion to instruments of 




pns forcops with narrow ami tapering blades. 



its class is omitted. Its working needs but brief notice. It is 
mounted with either annealed wire or fine piano wire, leaving a 
small oval loop projecting from a half to three-quarters of an 
inch. Passing the loop between the polypus and the septum, 
and turning it under the tumor, it is easily carried by a gentle 
motion to its attachment, when by holding the shaft of the 
snare firmly against the turbinated bone, from which the polyp 
springs, the pedicle can be leisurely cut through, and the tumor 
withdrawn with the instrument. Both the placing of the loop 
in position and the removal of the tumor are nearly painless, 
and attended with no hemorrhage whatever. The absence of 
bleeding renders it a very simple matter to proceed with the 
operation, and remove successive tumors as they come into 
view by the removal of their fellows. I have frequently at a 
single sitting removed numbers of polypi from each nasal 
cavity by this method, without hemorrhage, and with nothing 
more than the slight irritation of 23assing the wire into the cavi- 
ties. After the removal of polypi, it is best, as a rule, that the 



TUMORS OF THE NASAL CAVITY. 243 

part from which they are severed be cauterized by nitric acid 
or the galvano-caiitery, in order to guard against their recur- 
rence. 

VoTtolini and others recommend the use of the galvano- 
cautery for the removal of nasal polypi. The only advantage 
to be gained by its use would be in the coincident cauteriza- 
tion of the attachment of the tumor, otherwise the simple wire 
snare possesses all of its advantages, and, in addition, is much 
more easily manipulated and causes no pain. The cautery 
necessarily causes considerable pain at the time of the opera- 
tion, and also entails a week of no little discomfort from the 
irritation and swelling of the parts, which results from its use. 

As a matter of certainty in preventing a recurrence, as be- 
fore remarked, it is well to cauterize the parts after operating 
with the snare ; nevertheless, I am disposed to think that in 
many cases, if the instrument is properly and skilfully manip- 
ulated, that a radical cure is effected by its use. By pressing 
the loop firmly against the turbinated bone, not only is the 
polyp removed, but a sufficient portion of the mucous mem- 
brane is engaged to insure the complete ablation of the polypus- 
breeding tissue. 

Fibromata or Fibrous Polypi. — Fibrous tumors of the nose 
are of much rarer occurrence than those previously described, 
but they are far more serious in their import. They spring 
from the deep layers of the mucous membrane or periosteum, 
and are composed mainly of fibrous tissue, closely interlaced 
and embracing within its meshes a few connective-tissue cells 
and a somewhat scanty supply of blood-vessels. As a rule 
they spring from the posterior portion of the nasal cavity prop- 
er or vault of the pharynx, their attachment being to the bas- 
ilar process of the occipital or to the sphenoidal bone. Their 
growth is extremely slow, extending in every direction, and 
sending prolongations into neighboring cavities, but they 
extend by a resistless progress which nothing can withstand, 
carrying before them in their relentless march, membrane, car- 
tilage, and bone, or whatever may stand in their way. The 
symptoms at the onset are merely those due to nasal obstruc- 
tion without any noticeable catarrhal discharge, together with 
recurrent and often dangerous attacks of profuse hemorrhage 
from the raucous membrane surrounding them, which is much 
congested, and liable to become the seat of superficial erosions. 



244 DISEASES OF THE N^ASAL CAVITY. 

As tliey increase in size, and extend into the nasal cavity proper, 
they give rise to that peculiar deformity which is called frog 
face, due to the crowding forward of the re-entrant angle be- 
tween the nose and cheek bone. The diagnosis is easily made 
by inspection and palpation. 

Treatment consists in their removal by means of the forceps, 
the wire loop ecraseur, or by the use of the galvano-cautery. 
Access to these tumors may be obtained by opening the nasal 
cavity from in front, by dissecting up the face by incisions com- 
mencing at tlie angle of the lip and jaw, and carrying the dis- 
section upward until the upper lip and nose and cheek can be 
laid over upon the forehead, thus laying bare the bony orifice 
of the anterior nares. This is the operation of Bronge. 

Another and less formidable operation consists in making 
an incision from the inner angle of the eye to the angle of the 
mouth, and turning the nose to the opposite side by dissecting 
up the flap, thus reaching the same result of gaining a wider 
access to tlie nasal cavity. This is the operation of Langenbeck. 
Another method of reaching tliese tumors consists in making 
an incision through the soft palate, and, if necessary, extending 
it through the bony palate, thus gaining free access to the mass, 
which is then seized by a pair of stout forceps and torn and 
wrenched out. The clef t palate is then to be restored by an- 
other operation. The nicer manipulations brought into use since 
the introduction of the laryngoscope enable us to reach these 
tumors without involving the serious results of such formidable 
operations as the above. After a thorough investigation of the 
size and character of the tumor and the site of its pedicle, the 
wire loop being passed round it, it may be severed by the ecra- 
seur, or, what is preferable, the platinum wire having been 
passed, the pedicle can be cut by the galvano-cautery and the 
tamor removed through the pharynx. The advantage of this 
latter procedure consists in the freedom from hemorrhage. 
At best, however, this is liable to occur, and to an extent which 
is often most formidable, and the ingenuity and skill of the 
surgeon will often be put to a severe test in dealing with these 
troublesome cases, especially if the tumor has grown to a 
large size, as they not infrequently do, to the extent of filling 
up the anterior nasal cavity and even protruding from the nos- 
trils. This extent of growth would necessarily interfere some- 
what with the placing in position of the wire loop. Dr. Lincoln, 



EPISTAXIS OK NOSE-BLEED. 245 

of New York, lias reported some very successful operations on 
tliese large tumors in which their size was much reduced by the 
electrolytic needles before the radical operation was undertaken. 

Another method of dealing with these tumors consists in 
placing a ligature around the pedicle in such a manner that it 
can be gradually tightened until it cuts its way through. The 
tumor is strangulated by this procedure, and, of course, becomes 
necrosed. The discharges as the result of this plan become ex- 
tremely offensive and almost unendurable. This necessarily 
would render the procedure objectionable. Furthermore, if it 
is feasible to pass a ligature around the pedicle it is quite as 
feasible to pass the galvano-cautery wire, and hence the more 
rapid operation would seem the better one. 

It is claimed that the injection of the tumor with a strong 
solution of chloride of zinc will cause the growth to slough and 
come away. The same may be said of any of the escharotics, 
probably. The main objection to this plan of treatment would 
be in the intolerable stench which would necessarily attend the 
destruction of the mass. Occasionally these tumors undergo 
resolution, but such a fortunate accident is very rare. 



Epistaxis or Nose-Bleed. 

The mucous membrane of the nasal cavity is very abun- 
dantly supplied with blood-vessels, more so probably than any 
other portion of the air-passages, and owing to its exposed 
position and its liability to injury or irritation, bleeding is of 
extremely frequent occurrence. This may be the result of 
direct violence, as a blow or fall ; it may occur from picking 
the nose when it is the Seat of disease or irritation, or it may be 
due to an effort on the part of nature to relieve the surcharged 
blood-vessels of the head, when from an}^ cause the cerebral 
circulation is distended. In this latter case the bleeding is 
preceded by a sense of fulness about the forehead and eyes, 
frontal headache, dizziness or vertigo, intolerance of light, etc., 
all the symptoms disappearing with the escape of blood. Nose- 
bleed frequently marks the onset of typhoid or remittent fever, 
in which case it is accompanied by the ordinary symptoms of 
these diseases. It is also a prominent feature of scurvy, in 
wliicli case it will probably be accompanied by bleeding from 



246 DISEASES OF THE NASAL CAVITY. 

tlie gums and the characteristic blood spots upon tlie skin. 
It is said to take place at the monthly period, giving rise to 
the so-called vicarious menstruation, recurring as it does each 
month at the thne when the natural flow should appear, and 
which from some cause is suppressed. It occurs also in per- 
sons suffering from the hemorrhagic diathesis under the influ- 
ence of which any slight cut in any portion of the body is 
attended with violent and almost uncontrollable hemorrhage. 
If the bleeding is due to local causes, it is generally confined 
to one nostril, but if the cause is in a general condition, such 
as t3^plioid fever or scurvy, congestion of the blood-vessels of 
the head, etc., it flows from both sides of the nose. It usually 
trickles in drops, or flows in a small stream, and is not attended 
by any great danger, but it may become very serious or even 
fatal by its amount or long continuance without arrest. 

Treatment. — In the majority of cases, probably, the tend- 
ency of nose-bleed is to cease spontaneously, still it is not 
well to trust to this tendency, for if it lasts too long it is far 
more diflicult to arrest it than at the onset. Hence, simple 
measures should always be resorted tt), such as pressing the 
nose flrmly between the thumb and finger, thus closing the 
nostril, and as much as may be of the nasal cavity, at the 
same time raising the hand on the bleeding side as far as possi- 
ble. This position should be maintained from five to ten min- 
utes or even longer, the object of the procedure being to enable 
a clot to form by which the bleeding vessel may be plugged. 
Blowing the nose should be avoided, not only during the 
bleeding, but some time afterward, the effect of such an act 
being to dislodge the clot and re-establish the trouble. Resort 
at the same time should be made to the application of ice to 
the nose and also to the nape of the neck. In the absence of 
ice a piece of cold metal may be used. These measures fail- 
ing, a further resort is to tie a cord round one of the limbs, 
thus lessening the amount of blood which circulates in the ves- 
sels of the head, by detaining it in the extremities. If the 
hemorrhage is not arrested by these devices it will be neces- 
sary to use local applications such as persulphate of iron, 
ferric alum, tannic acid, gallic acid, about twenty grains to 
the ounce of water, which may be thrown in by the syringe or 
by the atomizer. If, however, the hemorrhage has been long 
continued and the patient shows evidences of suffering from 



EPISTAXIS OR NOSE-BLEED. 247 

loss of blood, as manifested by pallor in tlie face, weakness, 
vertigo, etc., time should not be wasted in the above proced- 
ures, but the physician should immediately resort to plugging 
the nostrils. Various devices have been resorted to for accom- 
plishing this ; prominent of course among them is the tradi- 
tional method by the use of Bellocq's canula, shown in Fig. 
107. By this instrument a thread is carried through the nos- 
tril into the pharynx, where it is seized by tlie forceps and 
brought out through the mouth and the instrument withdrawn. 
The cord will thus be so placed that one end hangs from the 
nostril and one from the mouth ; these two ends being tied to- 
gether, there should be fastened in the circuit of the cord 
a pledget of cotton, well oiled, which is now carried behind 
the soft palate and into the posterior nares, by traction 




Fig. 107. — Beilooq s canula. i 

on the cord protruding from the nostril, with the help of 
manipulation of the pledget by the fingers in the mouth. By 
this means the posterior nares is firmly closed, and the flow of 
blood into the pharynx arrested. Small pellets of cotton may 
now be packed into the nostril, and the hemorrhage will be 
under perfect control. The loop of the cord should now be 
drawn to one side and fastened to the ear. The pledget caii 
be left in position from twelve to twenty-four hours, when it 
may be safely withdrawn by traction on the cord passing out 
of the mouth. This procedure is more easilj^ described than 
performed, as in many cases the extreme irritability of the 
nose will render its performance very difficult. A procedure to 
which I have often resorted for controlling obstinate hemor- 
rhage, is to pack the nasal cavity with small pledgets of cot- 
ton from in front, the pledgets being soaked in some mild 
styptic such as a twenty-grain solution of ferric alum, persul- 
phate of iron or tannic acid, etc. These little pledgets being 
passed into the nostril can be carried back to the posterior nares 
by a iDair of slender forceps or probe, and gradually building up 



248 DISEASES OF THE NASAL CAVITY. 

by the additional pledgets the nasal cavity can be plugged very 
efficiently and without involving the difficulties ajid struggles 
necessary to accomplish the same end by Bellocq's canula. 

Dr. Robinson, of this city, has suggested for arresting epis- 
taxis, the introduction into the nasal cavity of a thin rubber 
air-bag, which, when in situ, can be inflated. For this purpose 
the simple toy balloon sold on the streets may be used, being 
fitted on a catheter. 

iVnother suggestion that has been seriously made is that of 
filling the nasal cavity with plaster-of-Paris, freshly mixed with 
water. This may be an efficient method of controlling tlie nose- 
bleed, but the difficulty would be in removing the plaster-of- 
Paris afterward. 

Any of the methods of passing a cord for tying the palate, 
described on page 29, are, of course, applicable for plugging 
the nares. 

Deviation of the Septum. 

This deformity is one of extremely frequent occurrence ; but 
in the large majority of cases it exists to so slight a degree 
that it gives rise to no inconvenience. Occasionally, however, 
it is met with where the deflection exists to such an extent as 
to cause a considerable degree of annoyance by the partial or 
even complete obstruction to nasal respiration. The deformity 
consists in the projection of the cartilaginous septum to one or 
the other side, generally to the left, the projection assuming the 
shape of an angular indentation. 

The diagnosis is quite simple, as it can generally be made by 
the appearance and feeling to the touch of the prominent mass 
in the obstructed nostril. The only condition with which it is 
liable to be confounded is that of a neoplasm ; but the diagno- 
sis becomes clear by an inspection of the other nostril which 
will reveal a corresponding depression. It is usually produced 
by a blow or fall upon the nose, although it not infrequently is 
a congenital condition. It often occurs in connection with 
fracture of the nasal bones, although it is more commonly met 
with independently of this condition. If the deviation occur 
in but a moderate degree the resultant symptoms are not suffi- 
ciently prominent to indicate treatment. In these cases, how- 
ever, in which the deformity leads to marked obstruction to 



DEVIATION OF THE SEPTUM. 



249 



nasal respiration, the condition will often demand relief at the 
hands of the physician. 

The part involved by the deformity being a thin and some- 
what tractable plate of cartilage, it becomes quite feasible to 
seize it by a properly constructed pair of forceps, and force it 
into a direct line with the vomer. This is the plan recom- 
mended by Adams, who published in the British Medical Jour- 
nal, October 2, 1875, an account of several successful operations 




Fig. 108. — Adams' forceps for the deposition of a deviated septum. 

of the kind. He used for the purpose a pair of strong forceps 
with flat parallel blades, shown in Fig. 108. The patient being 
under an ansesthetic, one blade is inserted into each nostril, 
and the deflected portion being grasped is wrenched into posi- 
tion. After this operation there is applied to the broken sep- 
tum a retentive apparatus shown in Fig. 109. This consists of 
a pair of flattened plates mounted with a hinge and worked 




Fig. 109.— Adiims^ 
Fig. 110.- 



screw compressor plates for deviated septum. 
-Adams' ivory plugs for tht nostril. 



by a screw. One blade is inserted into each nostril and the 
screw tightened sufficiently to retain the cartilage in position 
without making pressure on it. This apparatus is worn con- 
tinuously for three or four days and nights, after which tlie 
ivory plugs shown in Fig. 110 are introduced, and are to be 
worn until the cartilage has become firm. These plugs the 
patient can introduce or remove at pleasure. 

Another method of remedying a deviated septum consists 
in cutting out the offending portion of cartilage. This pro- 



250 DISEASES OF THE NASAL CAVITY. 

cedure, of course, establishes an artificial opening in the sep- 
tum ; but this is not sufficient to weaken the supports of the 
nose, and gives rise to no untoward symptoms. The operation, 
therefore, is a perfectly justifiable one. This may be accom- 
plished by means of Blandin's punch shown in Fig. Ill, which 
is fashioned after the ordinary shoe punch, but so modified 
as to enable it to be introduced within the nostrils. With 
this instrument small pieces of the septum can be successively 
clipped out until the deflected portion has been removed, after 
wliicli the parts heal kindly. There is, of course, some con- 
traction of the jiarts following the operation, w^liich in part 




Fig. 111.— Blanclins punch for use in deviation of the .septum. 

serves to close the opening, but the contraction is in a vertical 
plane, so that' the deformity cannot be re-established. Another 
plan of cutting away the deflected septum is by a small curved 
knife, but the punch would seem to afford a preferable means 
of operating. As preserving the integrity of the parts the opera- 
tion by the Adams method, however, will perhaps be resorted 
to rather than the latter plan. 



FoKEiGis^ Bodies ix the Nose. 

Children in their genius for mischief have a habit of put- 
ting small objects into the nose, mouth, and ear, which fre- 
quently give rise to serious trouble ; especially is this true in 
regard to the nasal cavity, in that the orifice is the smallest 
part, and their removal is far more difficult than their en- 
trance. Moreover, the timid child oftentimes refrains from 
telling what has happened, and an object wiiicli might easily be 
removed at first, becomes firmly fixed by the swelling of the 



ANOSMIA. 251 

mucous membrane excited by its presence. Sometimes foreign 
bodies get into the nasal passages without the individual being 
conscious of it at the time, and tlie immediate sjanptoms ex- 
cited by its presence being misunderstood, and soon subsiding, 
it may remain for years a source of irritation, exciting more or 
less profuse discharge, which soon becomes purulent in charac- 
ter, and a fetid catarrh is the result. The deduction from tliis 
is obvious. In every case of fetid catarrh the nasal cavity 
should be thoroughly cleansed and examined for the source of 
the offensive discharge. 

In removing foreign bodies from the nasal cavity all vio- 
lence should be carefully avoided. The object being brought 
into view, it should be seized gently with forceps and drawn 
out. A simple device which may be resorted to with children, 
and which may be mentioned in this connection, is often very 
efficient. It consists in blowing the child's nose for him as fol- 
lows : while the head is held steadily between the knees by an 
assistant, let the operator apply the lips closely over the mouth 
of the child, and blow forcibly into it. If the child cries, so 
much the better. The result of this is to drive a current of air 
behind the palate, and out from the nostril. It is not well to 
close the other nostril, since there is a possible danger of injury 
to the ears of the child by too great pressure on the tjia- 
panum. 

Anosmia. 

Anosmia or loss of the sense of smell occurs as the result 
either of conditions in the nasal cavity, which interfere with 
the function of the olfactory nerve, or from some central lesion 
in the brain itself. 

The sense of smell is dependent on the healthy condition 
of the mucous membrane of the nose, by which particles of 
odorous bodies coming in contact with the membrane are dis- 
solved by its mucus, and appreciated by the terminal filaments 
of the nerves ; hence any morbid condition of the mucous mem- 
brane of that portion of the nasal cavity to which the olfactory 
nerve is distributed, which interferes witli this process, neces- 
arily impairs or abolishes during its existence the sense of 
smell. Among the causes that may be enumerated as produ- 
cing this condition are dry catarrh, oz^ena, syphilitic disease, 



252 DISEASES OF THE NASAL CAVITY. 

tlie presence of tumors, and oftentimes hj'pertropliic catarrli, 
Tlie manner in which these diseases give rise to anosmia needs 
no explanation further than that of mechanical interference 
with the approach of odorous particles in a state of solution 
to the terminal filaments of the nerve. The other form of 
anosmia is that due to morbid conditions of the nerve-trunk, or 
the olfactory bulb, or still more central lesions. These condi- 
tions may be degeneration or atrophj^ of the nerve, tumors in the 
nerve or base of the skull, exostoses, caries, meningitis, etc. 
Other conditions which cause it are blows or injuries, especiall}^ 
blows on the occiput. Occasionally cases are met with of what 
has been called essential anosmia, in which the loss of smell 
occurs without any accompanying symptoms or assignable 
cause ; this is apt to occur in young women. 

The treatment of anosmia is essentially the treatment of the 
condition which causes it. If it is due to disease of the nasal 
cavity, we may say, as a rule, that the removal of the cause 
promises a restoration of the faculty. Those cases, howevei', 
which are of a neurotic origin, usually resist all treatment. 
The only plan of treatment which promises any hope of recov- 
ery is that by the use of electricity. Both the constant and 
interrupted currents are to be recommended. In connection 
with this the internal administration of strychnia may be em- 
plo3"ed. 



DISEASES OF THE LARYNX. 



CHAPTER XVI. 

CATAKEHAL AFFECTIONS OF THE LAEYNX. 

Anatomy.— The larynx is composed of a cartilaginous 
framework, containing within it certain muscles, ligaments 
and fibrous bands, and the whole lined with raucous mem- 
brane. The cartilages which enter into its formation are five 
in number : the epiglottis, thja-oid, cricoid, and two arytenoid 
cartilages. In addition to these there are four small carti- 
lages, or cornicula laryngis : the cartilages of Wrisberg and 
Santorini, two of each. 

Commencing from below, we find resting upon the upper 
ring of the trachea, the lower cartilage of the larynx, the cri- 
coid^ consisting of a stout ring rounded in its anterior two- 
thirds, which gives support to the thyroid ; broad and ex- 
panded in its posterior third, which gives support to the two 
arytenoids. It receives its name from its resemblance to a seal 
ring. Immediately above the cricoid cartilage, and resting 
upon its anterior portion, is the thyroid^ composed of two 
broad quadrilateral plates, which unite at an angle in front, 
the whole assuming somewhat the shape of a shield, from 
which it receives its name. At its re-entrant angle below, it 
affords insertion to the true and false cords, while above is in- 
serted the ligament of the epiglottis. 

Surmounting the expanded portion of the cricoid are the 
two arytenoid cartilages^ articulating with it by two facets. 
These are small triangular-shaped cartilages, with their apices 
turned inward and somewhat forward. The inner surface of 
each cartilage is smooth, and faces its fellow of the opposite 



254 DISEASES OF THE LARYNX. 

side ; the anterior surface gives attachment to the thyro- 
arytenoideus mnscle and to the ventricular band ; the pos- 
terior surface affords insertion to the inter-arytenoideus 
muscle. The base of the cartilage, in its anterior angle, gives 
attachment to the vocal cord, by means of a small projection 
which is called the vocal process of the arytenoid. The outer 
angle of the base of the cartilage is called the muscular pro- 
cess, and affords attachment to the adductor and abductor 
muscles of the cords. 

The eiyiglottls is a thin plate of cartilage, shaped somewhat 
like a leaf, and attached at its lower portion by a ligament to 
the receding angle of the thyroid. It varies very much in shape 
in different individuals, as shown in Figs. 16 — 21. In adults 
it stands up prominently, and projects to a distance above the 
upper border of the thyroid, while in children its crest rises 
but little above the lar3^ngeal cavity. It is attached to the 
thyroid by a freely flexible attachment, which admits of a 
motion of over 90°, extending from the vertical line to a de- 
pression upon the opening of the larynx. This movement is 
in the main of a passive character, as far as the epiglottis is 
concerned, although it is to an extent acted on by a few muscu- 
lar fibres in the ary-epiglottic fold. 

TJie cartilages of Santorini are two small cartilaginous 
nodules lying upon the apex of the arytenoids. They are 
endowed with no function and possess no especial points of 
interest. 

The cartilages of Wrisherg are two slender staff-like carti- 
lages found in the ary-epiglottic folds, and are seen as small 
whitish projections immediately in front of the arytenoids. 
They serve possibly as a support to the fold of membrane in 
which they are found. 

TJie cartilages of the larynx form a rigid framework or case, 
which is simply an expanded portion of the upper air-tract, so 
arranged as to afford lodgement for the apparatus designed to 
fulfil certain functions in phonation and respiration. For our 
present purpose it will be sufficient to describe those parts 
which are essentially concerned in the performance of these 
functions. They are the true and false cords and the muscles 
by which they are acted upon. 

TJie true vocal cords are composed of two firm bands of 
yellow elastic tissue, which pass from the anterior angle of the 



ANATOMY OF THE LARYNX. 255 

base of the arytenoid cartilage to the receding angle of the 
thyroid. Above these, and parallel with them, are the false 
T)Ocal cords, or more properly the Gentricular hands, two bands 
of fibrous tissue stretching from the anterior surface of the 
arytenoid cartilages to the receding angle of the thyroid, im- 
mediately above the insertion of the true cords. Between the 
true and false cords is found the 'ventricle of the larynx, an 
elongated recess which leads up by a narrow opening into a 
blind pocket called the laryngeal pouch or sacculus laryngis, a 
membranous sack which contains a large number of small folli- 
cular glands, whose function is to secrete mucus for the lubri- 
cation of the vocal cords. 

The muscles of the larynx are nine in number, one single 
muscle and four occurring in pairs. The latter are the crico- 
thyroidei, crico-arytenoidei postici, crico-arytenoidei laterales, 
and thyro-arj^tenoidei ; the single muscle is the arytenoideus. 

The crico-tliyroidei muscles arise from the anterior portion 
of the cricoid ring and are inserted into the lower and inner 
border of the thyroid cartilage. Their action is to draw the 
thyroid cartilage down upon the cricoid, thus increasing the dis- 
tance between the angle of the thyroid in front and the aryte- 
noid cartilages behind, rendering tense the vocal cords. 

Tlie crico-arytenoidei postici muscles arise from the poste- 
rior surface of the expanded portion of the cricoid cartilage, 
passing upward and outward to be inserted into the outer angles 
of the bases of the arytenoid cartilages. Their function is to 
rotate the arytenoid cartilages on themselves, throwing their 
anterior angles, into which are inserted the vocal cords, out- 
ward, thus opening the rima glottidis. 

The crico-arytenoidei laterales muscles why^q from the inner 
face and upper border of the side of the cricoid cartilage, and 
passing upward and backward are inserted into the-outer angles 
of the bases of the arytenoid cartilages. Their action is directly 
antagonistic of the crico-ar^^tenoidei postici muscles in drawing 
the outer angle of the cartilage forward, thus rotating its ante- 
rior angle, into which is inserted the vocal cord inward, closing 
the rima glottidis. 

The iJiyro-arytenoidei muscles arise from the receding angle 
of the thyroid cartilage, and are inserted into the anterior sur- 
faces of the arytenoid cartilages lying parallel and in contact 
with the outer border of the true cords. The function of these 



256 DISEASES OF THE LARYNX. 

muscles has never been clearly determined. They are often 
spoken of as the relaxors of the vocal cords, in that they draw 
the arytenoids toward the thyroids. It is difficult to under- 
stand what possible end could be accomplished by such an 
action. Relaxation of the cords is a purel}^ negative action, or 
rather, perhaps, passive in character ; it is accomplished with- 
out direct muscular contraction, but simply by a " letting go" 
of the muscles. Tension of the cords, on the other hand, is of 
the utmost importance in the nicer modulations of the voice, 
and can only be accomplished by direct muscular contraction. 
The existence of such a function in the muscular structure of 
the larynx is, of course, not questioned. If it does not lie in 
these muscles it lies in the crico-thyroidei, but a little consid- 
eiation of their position and character will show that they are 
scarcely capable of acting on the vocal cords to give them that 
delicacy of tension which they possess for the regulation of the 
pitch of the voice. 

The thyro-arytenoideus muscle is attached to the under- 
surface of the vocal cord throughout its whole extent, and the 
cord may, with propriety, be regarded as a tendon of the mus- 
cle. Its action as a tensor can be best illustrated by the famil- 
iar example of a rope stretched between two fixed points ; if it 
is moistened, its fibres absorbing the water, become swollen, and 
in distending laterally shorten longitudinall}^, thus rendering 
the rope more tense. 

Tlie arytenoideus is a single muscle passing from the pos- 
terior surface of one arytenoid cartilage, to the corresponding 
surface of the other, and consists of transverse and oblique fi- 
bres. The transverse fibres pass directly across from one car- 
tilage to the other, while the oblique fibres pass from the apex 
of one cartilage to the base of the other. The action of the 
arytenoideus muscle is to complete the closure of the rima 
glottidis by drawing together the cartilages. The necessity of 
tills action will be seen by reference to Fig. 134, for while the 
action of the crico-arytenoideus lateralis is to approximate the 
vocal cords, the closure of the rima is not completed. By the 
action of this muscle the vocal processes of the arytenoids are 
brought into apposition, closing the glottis from that point to 
the thyroid cartilage, but a triangular space is still left be- 
tween the vocal process and the arytenoid commissure which 
is only closed by the action of the arytenoideus muscle. In 



PHYSIOLOGY OF THE LAEYNX. 257 

addition to these nine intrinsic muscles we liave three small 
pairs of muscles belonging to the epiglottis. They are the 
thyro-epigiottideus, thearyteno-epiglottideus superior, and the 
aryteno-epiglottideus inferior. 

The tJiyTo-epiglottideus is a small muscle which arises from 
the inner surface of the thyroid cartilage near its receding an- 
gle and extends to the margin of the epiglottis. Its action is 
to depress the epiglottis. A few of its fibres are spread out 
upon the outer surface of the sacculus laryngis, while others 
are lost in the ary-epiglottic fold. 

The aryteno-epiglottideus superior muscle consists of a few 
muscular fibres which, having their origin at the apex of tlie 
arytenoid cartilage, pass forward and are lost in the ary-epi- 
glottic fold. The action of this muscle is to close the superior 
aperture of the larynx, and is especially brought into use in 
supplying the place of the epiglottis, when that cartilage has 
been destro3^ed, in preventing the entrance of food into the 
larynx during the act of deglutition. 

The arytenoideus epiglottideus inferior arises from the an- 
terior angle of the arytenoid cartilage and is spread out upon 
the sacculus laryngis, and is also inserted into the margin of 
the epiglottis. Its action is the same as the last mentioned 
muscle, with the addition that it acts to compress the sacculus 
larj'^ngis. 

The mucous membrane lining the larynx is covered with 
columnar ciliated epithelium in that portion which is below the 
border of the ventricular bands and also on the lower half of the 
epiglottis. The remaining portion of the membrane is covered 
with pavement epithelium. It is richly endowed with glands 
in all portions except ^n the true vocal cords. These glands 
are especially grouped in the arytenoid commissure and upon 
the epiglottis. 

The nerves of the larynx are the sujDerior laryngeal and 
recurrent laryngeal, both branches of the pneumogastric nerve. 
The superior laryngeal nerve supjDlies sensibility to the mucous 
membrane of the laryngeal cavity, and motion to the crico- 
thyroid muscle, and probably to the thyro-epiglottideus and 
the two aryteno-epiglottidei muscles. The recurrent laryngeal 
nerve is mainly the nerve of motion and supplies all the other 
muscles of the larynx. 

PiiYvSiOLOGY. — The larynx is of interest to us in the per- 
17 



258 DISEASES or the larynx. 

formanceof three functions, viz., in deglutition, respiration, and 
in the production of the voice. 

In the act of deglutition after the bolus of food has passed 
the isthmus of the fauces, the larynx, together with the phar- 
ynx, is drawn up by certain muscles acting through the hyoid 
bone, and at the same time drawn under the base of the tongue. 
By this movement the epiglottis falls over the superior opening 
of the larynx, which is thus protected from the entrance of 
food. That the epiglottis is not absolutely essential in protec- 
ting the larynx in the act of swallowing has been repeatedly 
demonstrated, both in man and the lower animals, the act being 
usually accomplished after the total ablation of this cartilage, 
without necessarily endangering the air-passages. The en- 
trance of the food into the larynx is prevented in these cases 
by the contraction of the aryteno-epiglottideus muscles, and 
also by the contraction of other muscles involved in the act, 
which press together the thyroid cartilages. 

In Tespiration the chink of the glottis is opened for the en- 
trance of air, by the action of the crico-arytenoidei postici 
muscles, while in expiration the muscles of the larynx are 
simply relaxed, the current passing from the lungs being suffi- 
cient to force open the glottis, as it were. This function of the 
larynx is carried on by means of the single pair of muscles above 
mentioned, which thus become among the most important mus- 
cles of the body, for the reason, that in the absence of this glottis 
opening function the vocal cords fall toward the median line 
under the action of the glottis closers ; the chink of the glottis 
becomes thus closed, and the breathing is either arrested or 
much hindered, giving rise to a most serious condition. 

The remaining function of the laryiix is in the production 
of the voice, which is formed by vibrations of the vocal cords, 
the larynx being regarded essentially as a reed instrument. 
The method by which the voice is formed, and its pitch and 
volume regulated, is extremely simple. The vocal cord proper 
is composed of dense fibrous tissue, covered by a very thin 
layer of mucous membrane, and is easily thrown into vibra- 
tions by a current of air forced through the chink between the 
two cords, which are kept at a certain tension, and also in ap- 
position by muscular action, the essential requirements for 
the production of a clear tone being that the cords shall be 
healthy, as regards conformation, and that muscular action by 



SUBACUTE LARYNGITIS. 259 

which they are approximated and made tense shall be nor- 
mally performed. The muscles by which the cords are approxi- 
mated are the crico-arytenoidei laterales. The tension of the 
cords is accomplished by the crico-thyroidei, and the thyro- 
arytenoidei, with the aid of the crico-arytenoidei postici mus- 
cles, which by their contraction hold the arytenoid cartilages in 
a lixed position. The special method of voice production is as 
f ollow^s : the air having been drawn into the lungs, the cords 
are approximated by the action of the crico-arytenoidei latera- 
les and the arytenoidei muscles, and made tense by the thyro- 
arytenoidei and crico-thyroidei. By the contraction of the pec- 
toral muscles the air is now driven with considerable force 
through the narrow chink thus formed between the cords, 
which are thereby thrown into vibration, these vibrations set- 
ting in play vibrations in the column of air filling the nasal 
and oral cavities. The volume of the sound is dependent 
mainljT- on the force with which the air is driven through the 
rima glottidis, while the pitch is regulated b}^ the tension of 
the cords. By this process the voice alone is formed, while 
articulation of the voice into language is accomplished by 
means of the soft palate, uvula, lips, and tongue. 

Before entering upon the consideration of special affections, 
it should be stated that there are certain morbid conditions of 
the larynx which are occasionally treated of as independent 
disorders. These are, anaemia, hypersemia, anaesthesia, and hy- 
peraesthesia of the lary nx. They are to be regarded as symptoms 
merely, and not distinct diseases, hence they will only receive 
consideration in so far as they .accompany other affections. 



Subacute Laryngitis. 

This is an inflammation of the mucous membrane lining the 
laryngeal cavity, acute in character, but of a mild type. It 
sets in somewhat suddenly, involves no especial danger, is at- 
tended with no alarming or painful symptoms, runs a limited 
course, and usually undergoes resolution in from five to eight 
days. The inflammatory action is confined mainly to the mu- 
cous membrane proper, and does not involve the submucous 
tissues. In this lies the distinction between subacute and 
acute laryngitis, for the essential gravity and danger of the lat- 



260 DISEASES OF THE LARYNX. 

ter affection is due to the fact that the morbid process involves 
the submucous celluhir structures, giving rise to an amount of 
tumefaction or oedema which does not exist in the milder dis- 
order. It is the result, in the large majority of instances, of ex- 
posure to cold, and in many cases we notice that it occurs from 
a very slight exposure. This is probably due to an already ex- 
isting laryngeal catarrh, the result of a neglected cold, which 
subsiding, has left behind it a very moderate inflammation of 
the mucous lining, which gives rise to symptoms of so trivial a 
character as to render it a source of no inconvenience, more 
than a liability to take cold easily. 

The inhalation of irritating vapors or gases, or the breathing 
of an atmosphere vitiated by dust or tobacco-smoke, may give 
rise to the affection, as may also the prolonged use or overstrain- 
ing of the voice in public speaking or singing. Especially is this 
the case if the organ is already the seat of a mild chronic catarrh. 

The damp and chilly atmosphere which prevails during the 
Spring and Fall months is a prolific cause of attacks of suba- 
cute laryngitis, which may be said to prevail almost endemi- 
cally at this time, while the clear cold of midwinter, as well as 
the heat of summer, afford a certain degree of immunity from 
the attacks. In the very large majority of instances this affec- 
tion occurs in those suffering from a chronic larj^ngitis, and 
consists in an acute exacerbation of the chronic disorder, as the 
result of an exposure to cold. This latter affection, as has 
been already shown, is one of the very frequent sequela of na- 
sal catarrh, hence a subacute laryngitis occurs in most cases in 
those suffering from the nasal ^disorder. Fui'thermore, a lia- 
bility to the occurrence of repeated attacks should suggest the 
probability of a morbid condition in the nasal cavity. 

Symptoms. — The prominent symptoms of the disease are a 
slight sense of irritation or tickling in the fauces, accompanied 
by a disposition to cough and clear the throat of the moderate 
accumulation of mucus which is secreted, together with more 
or less impairment of the voice, or complete aphonia. The de- 
gree and extent of the inflammatory process is limited, hence 
the amount of abnormal secretion is quite small. It consists 
of a thin muco-purulent discharge which is hawked or coughed 
up and voided, with but a partial sense of relief, as the con- 
gestion of the j)arts gives rise to a thick, swollen feeling in the 
throat which cannot be gotten rid of. 



SUBACUTE LARYNGITIS. 261 

The voice is either impaired or lost according to the severity 
of the attack. Tliis impairment of the voice sliows itself in 
hoarseness or marked lowering of its register, the cords being 
thickened by the congestion of the mucous membrane cover- 
ing them, and not admitting of the fine vibrations which pro- 
duce the higher notes. Occasionally the voice is entirely lost, 
being reduced to a mere whisper. This is, of course, not a 
serious symptom, and yet the gravity which attaches in the 
minds of the laity to aphonia, and the apprehension with which 
it is regarded, is often very great, although in subacute laryn- 
gitis it is a somewhat trivial sj^mptom, and, to an extent, ad- 
ventitious. It is not entirely due to thickening of the vocal 
cords, but rather to an infiltration of the mucous membrane 
covering the arytenoid commissure, which prevents their proper 
approximation. In addition to this it is probable that the 
muscular structures of the larynx are somewhat weakened by 
the morbid process in the membrane covering them. They be- 
come somewhat congested, and, possibly, the seat of a moder- 
ate degree of serous infiltration, which necessarily offers a me- 
chanical obstruction to their contraction. They do not respond 
readily to the nerve-current, hence adduction and tension of 
the cords is imperfectly accomplished, and an additional source 
of aphonia is present. The voice is reduced to a whisper, that 
is, the glottis is closed to the extent of producing a rushing 
sound in the current of expired air, but is not closed sufficiently 
to throw the cords into vibration, and this rushing sound is 
formed into articulate language by the lips, tongue, etc., in the 
same manner as the clear voice, producing the whispered voice. 
The complete aphonia does not always indicate that the attack 
is a severe one, as this symptom may occur in a mild attack, 
but rather that the arytenoid commissure is the seat of a more 
tlian usual congestion, or that the muscular structures are 
much weakened by the inflammatory process. 

In the milder cases the subjective symptoms are not very 
prominent, but in the severer cases there is occasionally consid- 
erable j)ain, referable to the region of the larynx, of a burning 
or smarting character, with more or less discomfort in swallow- 
ing and tenderness on external pressure. In these cases, also, 
congh is usually present, and often of an extremely irritating 
and ]iersistent nature. It commences with a mere tickling in 
th(3 throat which soon excites a cough, of a harsh, dr\' cliniac- 



262 DISEASES OE THE LARYNX. 

ter, the secretion being somewhat scanty. Not infrequently 
there is a sense of oppression referable to the chest region, and 
especially marked under the sternum. In these cases the cough 
becomes somewhat prominent, and quite persistent. The throat 
also becomes quite irritable, and the cough is excited by trivial 
causes, such as laughing, the drawing of a deep inspiration, 
etc. These symptoms, generally, are to be accounted for by the 
fact that the morbid process extends somewhat below the la- 
rynx and into the trachea. 

As the attack progresses, the secretion becomes somewhat 
increased in amount, and assumes a yellowish color, and some- 
thing of a muco-purulent character. The voice, also, if lost at 
the onset of the attack, is to an extent regained, yet still has a 
hoarse and a somewhat metallic resonance. This change in the 
character of the voice ensues as the secretion of the membrane 
becomes re-established, and the marked congestion which char- 
acterizes the first stage of the inflammation subsides, and there 
sets in the second or secreting stage. Fever is not usually 
present to any marked degree, but there is often a feeling of 
general malaise, with irregular, fleeting, muscular pains, and 
loss of appetite. 

Examination. — If now we inspect the parts there will be 
seen, in the milder cases, a diffuse redness of the mucous mem- 
brane lining the larynx, especially of that portion covering the 
arytenoid cartilages and commissure, and also the ventricular 
bands. There is no marked swelling of the parts, however, and 
the cavity is in no degree encroached upon. The membrane 
covering the vocal cords also presents the same reddened and 
congested appearance. 

In the severer cases the membrane presents a somewhat 
deeper injection, with a moderate but evenly diffused swelling 
of the portion covering the ventricular bands. This may be 
present to the extent, that the bands project over and partially 
conceal the true cords. 

The diagnosis is comparatively simple. There is no other 
affection which presents the same uniformly diffuse congestion 
of the lining membrane of the larynx, and involving the vocal 
cords, except acute laryngitis. The differential diagnosis is of 
importance, in that this latter affection, while an extremely rare 
one, is one of exceeding gravity, and the measures which must 
be resorted to for arresting its progress need to be of a very ac- 



SUBACUTE LARYNGITIS. 263 

tive character. The prominent differences between the two 
diseases are in the amount of swelling, and in the character of 
the discoloration of the membrane. In the graver affection 
the swelling is quite prominent, the lumen of the larynx being 
markedly encroached upon, which is not the case in the sub- 
acute form of the disease. And again, the membrane in the 
milder form is of an opaque reddened color, while in the graver 
affection it presents a humid, semi-translucent oedematous ap- 
pearance, especially marked over the arytenoids, ary -epiglottic 
folds, and the epiglottis. In addition to this, the symptoms 
are of a more alarming character in the dyspnoea, pain, fever, 
etc., which accompany acute laryngitis. 

Treatment. — While the disease is to an extent a self-limited 
one, it is doubtful if the laryngeal lining, after an attack which 
is allowed to run its course without treatment, reverts to an 
entirely healthy condition. This would suggest certain simple 
general measures in the way of prophylaxis ; this has alread}'' 
been alluded to, however, under the general subject of taking 
cold, in the chapter on that subject. Among the first and more 
important directions to be insisted upon, when an attack 
occurs, is that of absolute rest of the larynx. The infiuence 
of the unrestricted use of the voice in aggravating an attack 
of laryngeal catarrh is much underestimated. An ordinary 
conversation carried on by means of a larynx whose function 
is impaired by a simple catarrh, requires an additional effort 
to bring the muscles into play and the cords to a sufficient ten- 
sion for vocalization ; in singing, or loud talking, this effort is 
necessarily much greater, rendering necessary a straining of 
the voice Avhich cannot but have a deleterious infiuence on an 
existing inflammation ; hence this simple precaution cannot be 
too urgently insisted upon as of importance in limiting an ex- 
isting attack and avoiding the danger of its lapsing into a 
chronic infiammation of the laryngeal membrane. General 
remedies for the correction of the fever and malaise are neces- 
sary according to the severity of these symptoms, but, as a rule, 
are not prominently indicated. 

There are certain remedies whose internal administration 
has already been alluded to as exercising a controlling effect 
on inflammations of the upper air-passages. These are am- 
monia and cubebs. In a simple, mild attack, attended with no 
marked general symptoms, the administration of these reme- 



264 DISEASES OF THE LARYNX. 

dies will be sufficient, in connection with certain general direc- 
tions as regards rest of the voice, proper protection, avoidance 
of fresh cold, together with a few days' conlinement to the 
house. These may be given as follows : 

IJ . Ammonia carbonat 3 ij. 

Elixir simpl 3 iij. 

M. Sig. — One teaspoonful every four hours. 

I^ . Fl. ext. cubebffi ^ ss. 

Syr. aurant cort 3 j. 

Aquae ad. 3 iiJ. 

M. Sig. — One teaspoonful every four hours. 

5 . Pulv. cubeb^e 3 ss. 

Sacch alb 3 j. 

M. Ft. pulv., in chart. No. vi. div. Sig. — One powder 
every two hours. 

Occasionally these may be combined as follows : 

]^. Fl. ext. cubebse, 

Ammonia carbonat aa 3 ijss. 

Elixir simpl ad. 3 iij. 

M. Sig. — One teaspoonful every four hours. 

J^. Pulv. cubebse, 

]\Iur. ammonia aa 3 ss. 

Sacch. alb 3 i j. 

M. Ft. pulv., in chart. No. x. div. Sig.— One powder 
every two hours. 

If there is much cough an anodyne may be combined with 
the above remedies as follows : 

]J . Fl. ext. cubebse f ss. 

Tr. hyoscyami, 

S}^'. tolutani, 

Aquse aa 3 J. 

M. Sig. — One teaspoonful every four hours. 

B . Ammonia muriat 3 ij. 

Codeise gr. iij. 

Elixir simpl 3 iij. 

M. Sig. — One teaspoonful every four hours. 



SUBACUTE LAEYNGITIS. 265 

If the attack is a severe one, in addition to the administra- 
tion of the above, local applications should be resorted to. 
Without repeating what has already been said in regard to 
applications to the larynx, it is sufficient to state that in acute 
affections exceeding care should be exercised to use no irritat- 
ing application, and only to use such methods of making appli- 
cations as are easily tolerated. Brushes, sponges, and pro- 
bangs carried into the larynx, unquestionablj^ aggravate an 
existing acute inflammation and should be avoided. The 
laryngeal atomizer carries the fluid into the cavity and di- 
rectly upon the inflamed membrane, in a manner which is the 
least objectionable of any method we possess, and, wherever 
feasible, should be resorted to. Sass' tubes with compressed 
air, Fig. 62, afford the best means that we possess. Failing 
these, some of the other devices may be resorted to. The fluids 
to be recommended are as follows : Glycerole of tannin, 3 J. — 
3J., potass, chlorat.j gr. x. — sj., zinci sulph., gr. iv. — ?]*., 
sodse biborat., gr. x. — 3 j., aluminis sulph., gr. vi. — | J. 

If there is much congestion of the parts a more decided as- 
tringent than any of the above may be used as follows : Liq. 
ferri. persulph, gr. x. — | j., ferric alum, gr. vi. — 3 J. 

If the larynx is irritable, and the seat of much localized 
pain either on swallowing or on pressure, morphine may be 
added to any of the above prescriptions, of the strength of ten 
grains to the ounce. 

These applications should be made at least once each day, 
care being taken during the application not to weary the 
patient or irritate the larynx to too great an extent. The 
beak of the atomizer should be passed into the pharynx, its 
tip in such a position, beyond the crest of the epiglottis, that 
when the pressure is let on the jet will flood the larjmgeal 
cavity before reflex contraction can occur. It should be 
allowed to play but an instant, when it should be withdrawn 
and the patient permitted to rest. This procedure may be re- 
peated two or three times, when all will have been accom- 
plished that is necessary or feasible. Occasionally it will be 
best, before making the astringent applications, to clea.nse the 
larynx by the use of one of the cleansing solutions given in the 
Appendix, thrown into the cavity under the directions just 
given. 

Powders are neither well borne in acute inflammations of the 



266 DISEASES OF THE LARYNX. 

laryngeal cavity, nor are tliey of service. In the absence of a 
laryngeal spray it is doubtful if it is well to attempt local 
medication, as there is danger of doing quite as much harm as 
good by the introduction of the sponge or brush. 

Inhalations are much used in the acute inflammation of the 
laryngeal membrane, and are of unquestioned benefit. It is 
also an advantage that they can be managed by the patient at 
his own home. Any of the astringent remedies already men- 
tioned may be used by means of the steam atomizer. Fig. 66, 
under the same rules which would govern the choice of an 
agent for direct application by means of the spray-tubes. 

Another form of inhalation consists in making use of cer- 
tain remedies which are volatilized by hot water. Among the 
best of these for use in subacute laryngitis are, tinct. benzoin 
CO., and tinct. lupulin. A teaspoonful of the drug is to be put 
into a cup of hot water at a temperature of 120°, and the cup 
held under the mouth, and its vapor inhaled as long as any of 
the volatile principle is given off. A few drops of ol. picis, 
creosote, or carbolic acid, may be added occasionally, with 
benefit. If there is pain or soreness, opium or hyoscyami may 
be combined with the astringent. The more elaborate device 
for inhalation, shown in Fig. 67, may be used, but this is not 
essential to the efficacy of the remedy. Other remedies for use 
by inhalation are given in the Appendix. 

A physician's aid is often sought by public speakers or 
singers, who have contracted a subacute laryngitis a few hours 
or a day before they are under obligation to give an address or 
sing in public, and he is called upon to restore the voice at a 
few hours' notice, even if it is only a temporary one. If the 
request could be complied with, the temporary relief would be 
followed by a marked aggravation of the morbid condition, if 
the voice were subjected to the great strain which its use while 
enfeebled would require. But the request cannot be com- 
plied with, and I know of no remedy which will accomplish 
the desired result. The drugs which are said to afford this 
rapid relief are belladonna and aconite. The action of these 
agents on the fauces is familiar to all in producing an abnor- 
mal dryness, etc. The}^ have an undoubted intiuence on the 
vocal cords also. An individual suffering from an acute laryn- 
geal catarrh, with impaired or lost voice, if he will confine him- 
self to the house for the day and give his voice absolute rest, 



ACUTE LAEYISTGITIS. 267 

and at the same time take one or two drops each of tr. bella- 
donna and tr. aconite rad., every hour for three or fonr honrs 
before he desires to make use of the voice, will not infrequently 
notice a marked improvement, and even be able to subject it 
to a moderate effort. More frequently, however, the experiment 
will fail. Other than the above, I know of no plan of proced- 
ure which will accomplish the desired end ; and even in this 
plan I regard the rest and confinement to the house as the 
more active agents for good. The value of absolute rest to the 
vocal organ, in an acute inflammatory attack, cannot be over- 
estimated. If to this there be added confinement to the house 
and an equable temperature, it will be found, not infrequently, 
that the affection will disappear in but a short time. 

If, on the other hand, one suffering from one of these 
attacks subjects the organ to ordinary usage even, and also 
goes about in the open an-, the mere effect of the chilly and 
possibly damp atmosphere may serve to prolong and aggra- 
vate what might have been a comparatively trivial attack ; 
and also to prevent a complete resolution. The attack subsid- 
ing, there will probably ensue a chronio laryngeal catarrh. 



Acute Lahyngitis. 

This is an acute inflammation of the mucous membrane lin- 
ing the lar^'ngeal cavity, which, while of compai-atively rare 
occurrence, is one of an exceedingly grave and serious import, 
in that the grade of the morbid process is of an extremely ac- 
tive character, and that the deeper tissues of the membrane are 
involved. In the 8,000 cases treated at the Bellevue Throat 
Clinic in the past four years, there have presented but two 
cases of this disease occurring idiopathically.- Of course it is 
not to be anticipated that one suifering from a disease of so 
serious a character will present at a clinic for out-patients, still 
tliis fairly represents the extreme rarity of the disease. This 
fact is urged somewhat because we hear so frequently an ordi- 
nary subacute laryngitis spoken of as an acute attack. The 
distinction should always be made between the two diseases. 

The morbid process in acute laryngitis assumes a somewhat 
phlegmonous character, being attended by a considerable de- 
gree of swelling of the membrane, due in part to a certain 



268 DISEASES OF THE LARYNX. 

amount of serous infiltration, the result of the activity of the 
inflammatory action. 

The onset of the attack is usually quite sudden, being 
ushered in by a decided chill or by mere chilly sensations, fol- 
lowed by general febrile motion, manifesting itself in the hot 
and flushed skin, rapid pulse, pains in the muscles, headache, 
etc., the temperature rising to 102° — 104°. Following soon 
upon the febrile movement, there is a sense of burning and 
smarting referable to the region of the larynx, together with 
pain and tenderness on external pressure. Swallowing soon 
becomes difficult and jxiinful, on account of the lack of flexi- 
bility of the muscles of the fauces, and the pressure to which 
that act subjects the swollen and sensitive organ. Cough of a 
dry, irritating character soon sets in, together with hoarseness, 
or more commonly complete loss of voice. Dj^spnoea, depend- 
ent on the amount of (Dodema of the membrane, comes on quite 
early in the course of the attack, and may become of a very 
alarming character. 

Tlie disease generally arises from an exposure to cold, but 
w^liat other causes may operate as predisposing to, or as directly 
producing an attack of acute laryngitis, as the result of a cold, 
rather than a chronic inflammation of the membrane, it is diffi- 
cult to say. That children are more frequently attacked than 
aduUs is explained by the fact that in them the mucous 
membrane is very loosely attached to the parts beneath, and is 
eminently adapted to admit of serous exudations in its loose 
submucous cellular tissue, while in adult life the mucous mem- 
brane is quite closely adherent to the parts beneath, and there 
is a less amount of the deep cellular tissue. It occurs in appar- 
ent good health, and progresses rapidly, the exceeding activity 
of the morbid process being manifested from the very onset of 
the disease. It is still a purely catarrhal infiammation, that is, 
an inflammation not charactei'ized by any fibrinous exudation, 
but one in which the morbid process is so active and the 
blood-vessels so distended that very early in its progress 
serum is poured out from the engorged vessels, and infiltrates 
the tissue to the extent of producing mechanical obstruction 
to respiration, in that narrowest portion of the respirator}'' 
tract where a comparatively small obstruction may lead to 
grave results. A certain historical interest attaches to this dis- 
ease, from the fact that George Washington died from an at- 



ACUTE LAEYISTGITIS. 269 

tack lasting but twenty-four hours. It runs a rapid course of 
from five to seven days, tending to resolution at the end of that 
time, although there is danger of a fatal termination earlier in 
the course of the disease. The mode of death is by suffocation, 
resulting purely from the laryngeal obstruction. This is not 
due usually to the inflammatory swelling, but to a secondary 
oedema which is liable to set in at any time. 

Diagnosis. — This is of importance in the early stages of the 
attack, as giving warning of its dangers and indicating the spe- 
cial measures to be resorted to for warding them off. A laryn- 
goscopic examination, therefore, is of the utmost value in re- 
vealing the exact condition of the parts. There will be found 
the following appearances : the mucous membrane lining the 
larynx of a fiery red color throughout the whole cavity, pre- 
senting all the appearances of an active acute oedematous in- 
fiammation, the color being due to engorgement of the blood- 
vessels. The membrane is also markedly swollen, the swelling 
being especially prominent in those portions where its attach- 
ments are loose, and where there would naturally be room in the 
submucous cellular tissue for exudation. This is found in the 
ary-epiglottic folds and on the posterior face of the epiglottis, 
and to a less extent in the mucous membrane covering the aryte- 
noid cartilages and the inter-ary tenoid commissure. If the case 
is a severe one the swelling will be very great, and the red color 
of the arterial congestion will be masked to an extent by an 
(Dedematous exudation, as shown by a humid and watery ap- 
pearance of the membrane, giving it a semi- translucent aspect. 
The swelling may be so great as to seriously obstruct res- 
piration, due partiallj^ to the inflammatory infiltration and 
partially to the oedema resulting from it. 

Treatment. — The treatment must be prompt and vigorous 
from the very onset of the disease, as its progress is so rapid 
and the grave symptoms set in so quickly that they should be 
combated by every measure at our disposal. The patient 
should be kept in a warm room, at a temperature of 75° or 80°, 
and which is highly surcharged with the vapor of steam. This 
is easily accom])lislied by keeping a i^ot of water boiling in 
the room on a stove or over a spirit-lamp. In addition to this, 
local applications should be made directly to the inflamed 
membrane. This should be done by means of the larjnigeal 
spray, in preference to the brusli or sponge introduced into 



270 DISEASES OF THE LARYNX. 

tlie larynx. The solution to be nsed slionld possess decided 
astringent and anodyne properties, and be free from any irrita- 
ting qualities. To meet these requirements one of the following 
may be used in the order of preference. 

5 . Ferri et aluminis sulpliat gr. vi. 

Morphia sulpliat gi'- x. 

Aqua? 3J. 

M. Ft. lotio. 

I^ . Plumbi acetat gr. iij. 

Aq. ext. opii gr. xx. 

Aqu^e 3 j. 

M. Ft. lotio. 

I},. Aq. ext. opii gr. xx. 

Glycerine tannat 3 j. 

Aqufe ad. | j. 

M. Ft. lotio. 

These applications should be repeated every three or four 
hours, if necessar}^, until the graver sjanptoms have subsided. 

Inhalations of medicated vapors are, to an extent, of value 
during the intervals of treatment at the hand of the physician. 
The remedies that may be used in this manner are: ol. resin 
lupulin, tr. benzoin co., aq. ext. opii, and ext. hyoscyami, b}^ 
the methods suggested on p. 68. 

A better method, however, than the vapor inhalations is the 
steam atomizer shown in Fig. 66. This instrument, as has been 
before remarked, is of somewhat limited value in the treatment 
of chronic catarrhal affections ; in acute laryngitis, however, its 
efficienc}^ is undoubtedl}" marked. In directing its use in this 
affection, care should be exercised in its management, lest by 
its prolonged use harm may ensue. The inhalations should 
never be continued longer than three minutes, the mouth being 
held close to the aperture of the globe and the vapor taken by 
ordinary respiration and not by labored effort. The remedies 
which will prove efficient are as follows ; tannin, gr. v. — |j., 
infus. rhatany, infus. quercus alba, decoct, papaveri, etc. Al- 
coholic tinctures, as a rule, should be avoided as too irritating. 



CIIEONIC CATARRHAL LARYNGITIS. 271 

Tlie object of treatment in acute laryngitis is not to abort 
tlie attack, but to promote resolution by hastening the prog- 
ress of the different stages of the inflammatory process and to 
limit the graver features of the disease. The hot steam facili- 
tates the progress of the affection in relaxing the parts and 
promoting secretion, by which the swelling is reduced. 

The mild astringents which are used in connection with the 
hot steam have a tendency to reduce the congestion by constrict- 
ing the blood-vessels, and so limit the amount of serous exu- 
dation and cut short the duration of the attack. In addition 
to these local remedies, counter-irritants may be found of value. 
A small fl^'-blister, of three-quarters of an inch in diameter, 
should be applied over each wing of the thyroid cartilage. 

Hot fomentations, however, and poultices should be avoided, 
as also any bundling or muffling of the neck. Internal medica- 
tion, as a rule, is not indicated, the disease being a local inflam- 
matory affection, whose gravity depends, not on the extent of 
the constitutional s3anptoms, but on the importance of the func- 
tion of the part involved. Some benefit, however, may be 
counted upon in the administration of aconite in small doses, 
frequently repeated. Fleming' s tincture may be given in doses, 
from one to two minims, every two hours. With this there 
may be combined the sesquicarbonate of ammonia, from three 
to five grains. The administration of the tincture of iron, also, 
is undoubtedly of advantage, and may be given in alternation 
with the aconite and ammonia, in doses of from five to ten min- 
ims, administered in solution with glycerine as follows : 

I^ . Tinct. ferri 3 jss. — 3 ijss. 

Glyceringe ad. 3 ij. 

M. 

(Edema of the larynx is one of the prominent tendencies in 
acute laryngitis, and the one which will give rise to the great- 
est danger ; this will be considered in the section on that dis- 
ease. 

Chronic Catarrhal Laryngitis. 

This form of laryngitis is a catarrhal inflammation of tlie 
mucous membrane lining the larynx, of a mild type and chron- 
ic character, the main importance of which lies in its interfer- 



272 DISEASES OF THE LARYNX. 

ence with tlie nicer functions of the larynx in phonation ; and 
the moderate amount of annoyance due to the abnormal secre- 
tion from the membrane. It is due, not infrequently, to re- 
peated attacks of a subacute nature, which undergoing imper- 
fect resolution, leave behind a permanent morbid condition of 
the parts. In most cases, however, the affection is chronic from 
the commencement. In these cases it is due, generally, to a 
phar3^ngeal or nasal catarrh. The influence of these affections 
in producing laryngitis has not generally been recognized suffi- 
cienth^, but their influence is unquestioned in this direction. 
It may be stated almost as a rule without exception, that in 
all cases of chronic nasal catarrh of long standing, where there 
is hypertrophy of the glands at the vault of the pharynx, or 
marked thickening of the nasal membrane, that an examination 
of the laryngeal cavity will show it to be in a state of chronic 
inflammation. The method of its production is quite simple. 
The secretion from above, passing down the walls of the pha- 
rynx, falls directly upon the arytenoid commissure, and so 
makes its way into the laryngeal cavity. The long-continued 
and persistent action of this constant dropping in the throat, 
cannot but have an influence on the larynx which eventually 
leads to a chronic inflammation of its lining membrane. In ad- 
dition to this there is an unquestionable tendency, in a chronic 
catarrhal inflammation in the upper air-passages, to invade 
neighboring parts, from which the larynx is certainly not ex- 
empt. 

Furthermore, if a moderate catarrh of the larynx be estab- 
lished as the result of a nasal catarrh, it becomes subject to the 
aggravating influences already alluded to in connection with 
pharyngeal catarrh, which the existence of a morbid condition 
of the nares necessarily entails npon the upper air-passages. 
Normal nasal respiration being impeded, respiration is carried 
on through the mouth, and thus the air-passages are traversed 
by a current of dry,, cold, and impure air, which serves to ag- 
gravate any existing morbid condition. 

This matter of the dependence of a laryngeal catarrh on a 
nasal catarrh, I desire to assert with especial emphasis, for I 
believe it to be one wdiicli can be easil,y verified. In a some- 
what large experience, in dealing with these often intractable 
cases, I have repeatedly had this point impressed upon me, 
both by my failure to relieve the laryngeal trouble by confin- 



CHEONIC CATARRHAL LARYNGITIS/ 273 

ing measures of treatment to tliat organ alone, and again by the 
successful relief of the chronic laryngitis in at the same time 
directing treatment to the nasal disorder. 

Among other and common causes of a chronic laryngitis may 
be noticed, chronic catarrhal and follicular pharyngitis, chronic 
elongation of the uvula, and hypertrophied tonsils. The influ- 
ence of these afl'ections in developing the disease of the larynx 
is easily, understood, their influence being analogous to that of 
nasal catarrh. Chronic pulmonary afl'ections, whether of a 
simple catarrhal or of a phthisical nature, are generally accom- 
panied by a laryngeal catarrh. This is easily explained by the 
irritation to which the larynx is subjected in the constant 
cough which accompanies those affections, together with the 
discharges passing over it from below. 

Straining the voice is a not infrequent cause of laryngeal 
catarrh. This may occur in prolonged use of the voice ; in the 
attem]3t to give it a force or volume which it does not possess ; 
and in false singing. This latter vice consists oftentimes in 
carrying the notes beyond the normal register which belongs 
to any individual voice ; and also in changing from one register 
to another without altering the position of the larynx. The 
position in which the larynx lies in the neck in singing the 
chest-notes for instance is quite low, while when the head- 
notes are taken the larynx is raised and brought forward 
somewhat, while the plane of the cords is altered. It will be 
easily imderstood, then, if notes which belong to the head- 
register are attempted while the larynx is in the position for 
taking the chest-notes, that the action is only accomplished 
with a degree of effort which is almost painful. The result is 
that the voice is strained. It is a rule which is familiar to all, 
that a singer should never strike a note which cannot be taken 
with perfect ease and facility, and witliout labored effort. 

It is probable that what we call straining the voice consists 
in the rupture of some of theflbres of the tensor muscle, accom- 
panied possibly b}^ the rupture of some of the smaller blood- 
vessels. The result of this accident is to cause a mild subacute 
laryngeal catarrh, which soon subsides, leaving behind it a 
chronic catarrhal laryngitis. It is probable, furthermore, that 
in many of these cases the larynx is already weakened by ii 
mild morbid condition resulting from a nasal catarrh. This 
affection oftentimes exists without being recognized inpatients 
18 



274 DISEASES OF THE LARYNX. 

wlio having little cause to use the voice in singing or prolonged 
talking are unconscious of the presence of any trouble in the 
larynx, more than the slightly abnormal secretion, the laryn- 
geal catarrh being overlooked in the more annoying nasal ca- 
tarrh. 

Symptoms. — The symptoms of a chronic laryngeal catarrh 
are not ordinarily prominent. There is a more or less excess of 
secretion, with a disposition to clear the throat, and an oc- 
casional huskiness of the voice, with oftentimes a tickling irri- 
tating cough, which is quite prominent in the damp days of 
Spring and Fall, but generally absent in the winter and sum- 
mer months. The prominent feature, however, of the disease 
is in its influence on the voice, and to those whose occupation 
requires the use of this organ, either in singing or public 
speaking, the existence of a chronic catarrh of the larynx be- 
comes a matter of considerable gravity. There is congestion of 
the mucous membrane, with more or less thickening, which ex- 
tends to the true cords. Their size is increased, and as a natural 
result their nicer vibrations are in a degree interfered with ; 
the muscular apparatus of the larynx is also weakened to a 
certain extent; there is loss of muscular control. This is 
especially marked in the tensors, the thyro-arytenoid muscles, 
which become relaxed, giving rise to that condition which is 
sometimes spoken of as elliptical paralysis of the cords. The 
result of this increased size of the vocal cords, together with the 
lack of proper muscular power to make them tense, is obvious ; 
the production of the higher notes becomes impossible from 
lack of tension and the whole voice register is lowered. This, 
in moderate talking and limited use of the voice, is not es- 
pecially noticeable, but if prolonged use of the voice is at- 
tempted the patient soon becomes conscious of the excessive 
muscular effort required, and the voice tires. Furthermore, as 
a result of this increased effort, this straining of the voice, the 
cords become congested and the voice rapidly husky or com- 
pletely aphonic. 

In addition to the weakness of the voice there is a slightly 
irritant condition of the larynx, an occasional tickling in the 
throat, and disposition to cough, the cough being dry, and 
somewhat stridulous in character, preceded generally by the 
irritation in the fauces, with a disposition to clear the throat. 
This is oftentimes more troublesome at night than in the day- 



CHRONIC CATARRHAL LARYNGITIS. 275 

time. There is also an especial liability to recurrent attacks of 
subacute laryngitis, with more or less complete loss of voice. 

Examination, — ^An inspection of the larynx reveals the 
whole mucous membrane lining the organ congested, and of a 
deep red color, verging on a purplish hue, the redness being 
more marked over the false cords and arytenoids. The normal 
pink tint of the healthy mucous membrane is almost entirely 
lost in this deeper red color. The parts present a som-ewhat 
opaque appearance, the yellow tinge of the cartilages, which is 
seen through the healthy membrane, is lost, their color being 
concealed by the thickened and congested membrane. The 
commissure of the arytenoids presents a thickened, puffy ap- 
pearance often, with a tendency to a pouching anteriorly be- 
tween the arytenoid cartilages, and overhangs somewhat the 
posterior insertion of the true cords. 

This thickened condition of the commissure may cause a 
mechanical interference with the proper approximation of the 
cords, thus adding to the loss or impairment of voice. The 
ventricular bands or false cords occasionally will be seen 
swollen to the extent that they project over the true cords and 
partially conceal them. The true cords themselves, owing to 
the delicacy of the mucous membrane which covers them, the 
absence of any glandular structures in it, and the limited sup- 
ply of blood-vessels, show in place of a reddened and congested 
appearance a grayish, ashy discoloration. They are usually 
covered by a very moderate amount of thick, tenacious mucus, 
but occasionally have the appearance of cleanliness. 

On phonation there will be usually noticed a lack of per- 
fect parallelism during the act, indicating that the tension of 
the cords is imperfect ; they bow out, leaving an elliptical- 
shaped opening between them. This may be more marked on 
one side than on the other. In extreme cases this relaxed con- 
dition of the cords, as already mentioned, has been called 
paralysis of tension, or elliptical paralysis of the cords, and is 
usually described under the head of neuroses of the larynx. 
That this disease is of nervous origin is open to question, or 
that it constitutes a separate and distinct disease. I have 
never seen a case of so-called ellii^tical paralysis which was not 
attended with chronic laryngeal catarrh, and rarely a case of 
chronic laryngeal catarrh which was not attended with some 
degree of impairment of the tension of the cords. As has been 



276 DISEASES OF THE LAEYNX.^ 

before stated the chronic catarrhal inflammation of the anem- 
brane lining the larj'nx gives rise to a morbid condition in the 
muscles lying beneath it, not perhaps to a condition of in- 
flammation of the rauscnlar tissue, but yet to a moderate degree 
of infiltration which interferes with its proj^er function. This 
is especially true of the thyro-arytenoid which lies immedi- 
ately beneath the mucous membrane and in close contact with 
the vocal cords. 

Treatment. — It is of the utmost importance, in the treat- 
ment of this affection, that we should recognize the existence 
of the cause of the affection and remove it. As above stated, 
a large proportion of cases are due to nasal catarrh. This 
may be overlooked while attention is directed entirely to the 
larynx ; hence, both by physical examination and by question 
eliciting the subjective symptoms, a nasal catarrh, if present, 
should be discovered and removed by proper remedies. 

The same may be said of pharyngeal catarrh, enlarged ton- 
sils, elongated uvula, etc. All remedies directed to the re- 
moval of the morbid condition within the larj^nx are of little 
avail as long as an exciting or aggravating cause exists to per- 
petuate the trouble. As regards the habit of smoking, the 
same is true here, as in regard to pharjmgeal catarrh, but to 
no greater degree : that, wiiile smoking is a pernicious habit 
— or perhaps rather a dirtj^ habit — its influence on catarrh of 
the upper air-passages is much overestimated ; and while in 
many cases it aggravates an existing trouble, and consequently 
the habit should be interdicted, yet in most cases it is harm- 
less. It is my belief, in regard to this vexed question, that the 
absorption of nicotine, in excessive smoking, is the harmful 
feature of it, not the local, irritating qualities of tobacco 
smoke on the air-passages, and that tlie physician's advice in 
regard to its use should be based more upon its influence on 
the general system than on its local effect. It may be stated, 
however, in this connection, that, as a matter of clinical obser- 
vation, the injurious effect of smoking, or the use of tobacco in 
any form, is more marked and noticeable in chronic follicular 
troubles than in simple catarrhal inflammations. 

In addition to the avoidance or removal of those causes 
which aggravate or predispose to laryngeal catarrh, certain 
measures should be resorted to for the correction of the mor- 
bid condition in the organ. These consist in the apj)lication 



CHKOlSriC CATAEEHAL LAEYNGITIS. 277 

directly to the laiyngeal mucous membrane of remedies whose 
action is to reduce congestion, arrest abnormal secretion, and, 
in short, give tone to the membrane and indirectly to the 
muscles. This brings us again to the question of topical appli- 
cations in the larynx already alluded to. Little remains to be 
said here in addition to what has already been stated. What 
is true in regard to acute affections in the larynx is also true in 
regard to the chronic. The laryngeal membrane is extremely 
sensitive, and intolerant of the introduction of foreign bodies, 
whether introduced by accident, or by design at the hands of 
the surgeon ; hence, any method by which we can make 
applications to the larynx, without irritating it, would seem 
desirable. The atomizer accomplishes this purpose better than 
any other method we possess for local applications ; hence, where 
available, its use should always be resorted to in preference to 
any other. The proper method of managing applications to 
the larynx, by means of the atomizer, has already been de- 
scribed, page 59. Free access to the laryngeal cavity for the 
spray is occasionally prevented by an overhanging epiglottis 
or some other impediment. In these cases resort will neces- 
sarily be had to the use of the brush or sponge. My own pref- 
erence is, however, for the cotton pellet — a small piece of cot- 
ton being twisted firmly on the end of a laryngeal probe. If 
properly prepared there is no danger of its becoming detach- 
ed, and it takes up but a moderate amount of the fluid to be 
used. 

This is one of the diseases in which nitrate of silver is of the 
greatest value, if used of the proper strength, and of great in- 
jury if improperly used. It should be applied of the strength 
of gr. iij. — XV. to 3]'. The stronger solutions are not only lia- 
ble to excite most painful spasm of the glottis, but are also 
positively injurious. Nitrate of silver is not only an astringent 
but is a i^owerful stimulant, and this is one of the ends to be 
sought in the treatment of the disease under consideration. 
The grade of inflammation is an extremely slow and sluggish 
one, and the morbid process essentially chronic, hence the flrst 
end to be Sought is the stimulation of the nutritive processes 
of the membrane to a healthier activity. Next in the order of 
preference to the nitrate of silver should be placed chloride of 
zinc, which may be used of the strength of gr. v.— xv. to 3 j- 
Among other remedies possessing efficiency are, zinci sulph., 



278 DISEASES OF THE LARYNX. 

gr. X. — XX. to 3 j., cupri snlpliat., gr. v. — xv. to 3 j., alum, gr. 
X. — XX. to 3 j., potassse clilorat., gr. x. — 3 ss. to 3]'., etc. 

Powders are occasionally recommended in this affection ; they 
should, however, as a rule, never be used in any catarrhal in- 
flammations in the larynx, as the irritating qualities of the 
powder are liable to cause more injury than can be counterbal- 
anced by any good which may be accomplished by the astrin- 
gent which it contains. The use of the syringe in laryngeal 
catarrh should never be resorted to, as the bulk of the fluid 
which it carries is apt to excite severe spasm. The use of 
steam inhalations or vapors should be avoided in this affection 
or in any form of chronic inflammation, as their tendency is 
to produce congestion and relaxation of the parts, which are 
the conditions which it is the effort of the physician to control. 
As a rule, it is w^ell, before using the astringent application, to 
throw a cleansing solution, by means of the spray apparatus, 
upon the diseased membrane, thus removing the mucus which 
covers it, and allowing the astringent or other medicament to 
come directly in contact with the membrane itself. 

In making these applications careful attention should be 
paid to the directions already given on page 60, for spraying 
the larynx, care being exercised not to weary the patient, or to 
weary the organ by allowing the atomized fluid to play upon 
it more than a few seconds at each introduction of the tube, nor 
to repeat the procedure too often. In the intervals of treat- 
ment the patient oftentimes will be benefited by the use of cold 
inhalations of one of the astringents given above, used with a 
simple atomizer such as that shown in Fig. 63, or even one of the 
small cologne atomizers which are found on any toilet table. 

While under treatment, the patient must be absolutelj^ for- 
bidden to subject the larynx to the strain or weariness which 
its use in singing or public speaking would necessarily entail. 
It is well also to avoid the too prolonged use of the voice even in 
ordinary conversation. 

At best the treatment of chronic laryngeal catarrh, by topi- 
cal applications and general hygienic measures combined, is 
very unsatisfactory unless it is remembered that in a very 
large majority of cases the disease is directly due to a pre-ex- 
isting condition, as nasal catarrh, pharyngeal catarrh, an 
elongated uvula, etc., and that the laryngeal disease can only 
be cured by first removing its exciting cause. 



(EDEMA OF THE GLOTTIS. 279 

111 addition to the above outlined plan of treatment tliere 
should be borne in mind the tendency of the intlammatory con- 
dition to impair to an extent the muscular structures, and 
these must therefore receive attention. For this reason the 
use of the faradic current should be resorted to, in addition 
to the topical medication. For this purpose I generally use 
the ordinary single-cell office battery, holding one electrode in 
the hand and directing the patient to hold the other. The ap- 
plication is then made by placing the other hand over the thy- 
roid cartilage, as near as possible to the anterior insertion of 
the thyro-ary tenoid muscles. This plan I have found to answer 
an excellent purpose, as it avoids the unpleasant features of 
passing the electrodes inside the laryngeal cavity. 



(Edema of the Laeynx or (Edema Glottidis. 

Owing to the fact that the mucous membrane lining the 
laryngeal cavity is loosely attached to the parts beneath, and 
that the submucous cellular tissue admits of considerable play 
of the membrane upon the parts to which it is attached, the 
occurrence of serous exudation within the submucous tissues 
is of not infrequent occurrence. This is especially true in 
children where the mucous membrane is far more loosely at- 
tached in the cavity of the larynx than in adults. The affec- 
tion may be caused directly by the inhalation of irritating 
vapors, chemical irritants, hot steam, etc., or by the swallow- 
ing of acrid poisons which give rise to an inflammation of the 
fauces which extends to the larj^'nx. It may result also from 
the presence of foreign bodies. In addition to these direct 
causes there are certain predisposing causes which have a very 
powerful influence in producing this affection where there al- 
ready exists some slight local morbid condition inviting the 
oedema; occasionally, however, acting directly without any 
apparent predisposing cause. These affections are acute and 
chronic nephritis, or Bright' s disease, obstructive disease of 
the heart, emphysema of the lungs, fibrous phthisis, or any 
disease whose tendencj^ is toward the production of dropsy, 
localized or general. The direct result of these affections may 
be the production of oedema of the larynx, but, as a rule, there 



280 DISEASES OF THE LARYNX. 

is some condition which invites serous exudation to the part, 
as a chronic laryngitis, ulceration, or tubercular disease, etc. 
The onset of the attack is, usually, verj^ sudden, and the ob- 
struction to respiration, which is the prominent symptom of 
the disease, and the one feature which renders the affection 
an extremely grave one, sets in almost immediately. 

The dyspnoea at the commencement of the attack is usually 
with inspiration alone, expiration being easily accomplished. 
This is owing to the action of the in\Vard current in crowding 
together the swollen ary-epiglottic folds, which thus act as a 
sort of a valve. This soon disappears, however, and the ob- 
struction shows itself in both acts of respiration. The subject- 
ive sjauptoms are very marked and distressing in character, 
the breathing becomes very labored, all the muscles of the 
chest are brought into vigorous action to assist in carrying on 
the respiratory act, and the painful effort by which this is 
done and the manner of its accomplishment, is evidenced by 
the pallid features, the staring eyes, the cold perspiration 
standing out upon the face, the restless tossing of the patient, 
with the terror and anxiety which characterize every move- 
ment and appearance. These symptoms, however, merely 
point to laryngeal obstruction, from some cause, and a certain 
diagnosis can only be made by digital and laryngeal examina- 
tion. 

Examination. — Occasionally, by depressing the tongue, 
tlie crest of tlie epiglottis will be brought into view, standing 
up prom'inently at its base, and presenting the characteristic 
oedematous, watery, semi-translucent tumefaction which marks 
the disease. This method of examination, however, is not 
usually available. B}^ passing the linger back over the base 
of the tongue it will generally be found feasible to explore 
the laryngeal cavity, and to recognize the existence . of the 
oedema, and also its extent. The introduction of the laryngeal 
mirror, however, will complete the diagnosis. This must, 
of course, be done with considerable rapidity and deftness, as 
the patient, suffering from the intense dyspnoea, can only with 
the greatest possible effoi't remain quiet sufficiently long to 
allow of an examination being completed. A rapid glance at 
the part by means of the mirror, however, will be sufficient to 
enable the observer to recognize the characteristic swellings 
which produce the obstruction. (See Fig. 112.) There will be 



(EDEMA OF THE GLOTTIS, 281 

found projecting into the lumen of the larynx, as a rule, two 
rounded tumefactions which have their origin in the ary-epi- 
glottic folds, and extending to and involving tlie posterior sur- 
face and crest of the epiglottis. At times the ary-epiglottic 
folds have the appearance of two rounded oblong masses, lying 
almost in apposition and showing an evident tendency to roll 
inward, as it were, upon the larynx, with every act of inspira- 
tion. The arytenoids form, also, small rounded masses which 
lie behind the diverging angle of the ary-epiglottic folds, com- 
pleting the closure of the larynx, except the small triangular 
opening at the point of meeting, and even 
this may be so small as to be scarcely de- W / j 

tected. The swelling is rarely of a sym- ^^^^S 
metrical character, but is apt to be more ^^^P 
extensive on one side than on the other, 
and at the same time of a somewhat I 

irregular outline. If purely a case of / 

passive oedema, as the result of Bright' s %^^ -^^^ 

disease, cardiac disease, etc., the swol- ^ ^ '"^ 

len masses will present a grayish- white ti/Tcohen")™""''"^ ^^^ ^^°*^ 
semi-opaque color, with a humid or wa- 
tery appearance verging on a pinkish or reddish color where 
the oedematous swelling emerges from the more closely attached 
membrane which is free from oedema. If, however, the attack 
is due to a direct irritating cause, as in acute laryngitis, or the 
result of the inhalation of hot steam, flame, irritating vapors, 
or the presence of a foreign bodj^, there are seen the evidences 
of active acute inflammation of the membrane which is, accord- 
ing to the severity of the inflammatory process, of a deep fiery 
red or deep pink color, fading to a whitish-gray in those parts 
most distended by the fluid exudation. It is covered more or 
less with thick frothy mucus or sero-mucus, the removal of 
which becomes diflS.cult or impossible by any effort on the part 
of the i^atient, partly from the paralysis of the villi of the 
membrane, and partly from the general impairment of the 
functions of the whole laryngeal apparatus. 

Treatment. — If the afllection is one of pure and uncompli- 
cated oedema, the result of a general blood condition, or is 
caused by heart or kidney disease, it is questionable if any of 
the ordinar}^ local applications will be of any benefit. In these 
cases the oedema comes on so suddenly, and the grave symp- 



282 DISEASES OF THE LARYNX. 

toms develop so early in the attack, that it is only by the most 
prompt and efficient measures that the physician will be en- 
abled to give relief to the obstruction before a fatal termination. 
In fact, in many of these cases, the disease runs its course so 
rapidly that death ensues before the physician can be sum- 
moned. Without waiting, therefore, for the doubtful results of 
local applications, the physician should proceed immediately 
to the tapping of the little bags of serum and letting the water 
out, in which case they will be seen to colhipse almost imme- 
diately, and the dj^spnoea be relieved. This operation is not 
necessarily a difficult one and can be performed without the 
use of the mirror. The finger of the left hand being passed 
down to the larynx, the proper scarifier -held in the right hand 
is carried down, and, using the left finger as a guide, several 
long sweeping incisions are made into the membrane when it 
will collapse readily. 

The use of the mirror, if feasible, renders the operation 




Fig. 113 — Buck's laryngeal scarifier. 

more simple, in that the point of the knife can be easily seen, 
and the depth and extent of the incisions carefully guided, and 
at the same time the whole of the oedematous swelling, as far as 
it extends, can be scarified. An ordinary sharp pointed, curved 
bistoury, with its blade wrapped with twine up to within a 
quarter of an inch of its point, may be used in the absence of 
any better instrument, or the ordinary gum lancet of the pock- 
et-case proves a veiy serviceable substitute for the laryngeal 
scarifier. 

Fig. 113 shows Buck's laryngeal scarifier, which is a more 
serviceable instrument if at hand. 

Tobold's lancet. Fig. 114, which consists of a small lancet 
concealed within a tube, and which is only protruded at the in- 
stant of use, is probably as good an instrument as can be de- 



(EDEMA OF THE GLOTTIS. 283 

vised for this operation. Its manipulation should be guided 
by the mirror. If the dyspnoea is not relieved by scarification, 
preparation should be made for tracheotomy, and this should 
be done if the symptoms at any time become alarming. 

In oedema from acute laryngitis, tuberculosis, syphilis, or 
any of the localized diseases of the larynx which tend to the 
production of serous exudation, resort may be had with bene- 
fit to the use of some mild astringent in connection with steam 
inhalations. In these cases preference should be given to the 
use of some of the metallic astringents, among the best of which 
are, ferric alum, alum, or sulphate of iron, ten grains to the 
ounce. These may be used with the steam atomizer shown in 
Fig. 66, the inhalations being given as often as every hour. If 




Fig. 114. — Tobold's concealed lancet for oedema glottidis. 

the symptoms are not alarming and the oedema has not pro- 
gressed to any great extent, this will be sufficient to relieve and 
remove the difficulty. In addition to this the patient should 
be kept in a warm room, at a temperature not lower than 75°. 
Applications about the neck are of doubtful benefit. Hot 
fomentations, poultices, blisters, and sinapisms have all been 
recommended, as well as cold applications, ice-bags, etc., over 
the larynx. These applications certainly add nothing to the 
comfort of the patient and probably nothing to the relief of his 
oedema, and it is quite as well, as a rule, to leave the neck open 
for the free play of its muscles, and perfectly clear and clean, 
depending entirely on the internal applications in the order of 
the urgency of the symptoms, with the certainty always that 



284 DISEASES OF THE LARYNX. 

if necessity demands, the physician has at hand in -tracheotomy 
a resort which will be thoronghly effectual in counteracting all 
dangerous tendencies, and which should be promptly resorted 
to when astringent inhalations or scarification fail to relieve. 
After the performance of tracheotoni}^, topical applications may 
be resorted to for the relief of the local conditions which have 
given rise to the oedema, but in the case of primary oedema it 
o-enerally subsides rapidly and requires no further treatment. 



CHAPTER XVII. 

LAEYNGEAL PHTHISIS. 

W ITHOUT entering into tlie question of tubercle, in its rela 
tions to laryngeal phthisis, it is sufficient to say that the old 
controversy is apparently no nearer to a settlement than before, 
and that the advocates of one or the other side of the question 
hold to their convictions and report the results of their investi- 
gations with the same positiveness. My own convictions on the 
question are, that laryngeal phthisis is not necessarily of tu- 
bercular origin primarily, but of inflammatory origin ; and that 
if tubercles are found on autopsy they are simply the scatter- 
ed gray nodules which are frequently found about the base 
of any chronic ulcerative disease. This view is held as more 
perfectl}^ harmonizing with the development and clinical his- 
tory of the disease, and more clearly explaining the pathologi- 
cal changes met with during its course, than that view which 
upholds its tubercular character. Laryngeal phthisis ma,j be 
defined as a disease characterized by the development in the 
mucous membrane of the larynx, under the influence of some 
marked, general, and non-specific dyscrasia, of an ulcerative 
process, chronic in character and slow in its destructive prog- 
ress, which commences in the superficial layer of the mem- 
brane, and, if not arrested, extends to the deeper tissues, at- 
tacking the perichondrium and cartilages and involving them 
in caries and necrosis. 

In the lai'ge majority of cases it occurs in connection with 
chronic pulmonary disease, but we meet wi^h it alike in tuber- 
cular and non-tubercular disease of the lungs. As a rule it oc- 
curs after the development of the lung trouble. Many writers 
assert that it never occurs as a primary disease, but that it is 
always a sequela of lung disease. I have seen several cases in 
which the disease manifcjsted itself in tlie larynx before it was 
possible to detect any pulmonary affection. In those cases, 



286 DISEASES OF THE LARYXX. 

however, in which the laryngeal phthisis is primary, there is 
always manifest a markedly impaired condition of the general 
health. It may also occur in scrofula, syphilitic asthenia, 
anaemia, chlorosis. Bright' s disease, or any of those general 
conditions which seriously impair the health and weaken its 
power of resisting disease. The upper air-passages, exposed as 
they are to the first ingress of inspired air, with its varying 
temperature and condition of dryness or humidity, exposed 
also to the deleterious influence of whatever of imi^urities it 
may contain, such as irritating vapors or gases, and particles 
of dust, are exceedingly liable to take on catarrhal inflamma- 
tion. The larynx is also the seat of a constant functional ac- 
tivity in the various movements involved in the acts of phona- 
tion, respiration, and deglutition, the influence of which, in 
aggravating an existing morbid condition, we are liable to 
underestimate. If, then, a patient, suffering from any general 
dyscrasia such as Bright's disease, scrofula, chlorosis, anaemia, 
etc., or any of the conditions which lower the vitality of the 
system and lessen its power of resisting disease, from any cause 
acquires a laryngeal catarrh, it is easy to understand how the 
simple catarrhal inflammation of the membrane may lapse into 
an ulcerative process, and there be developed that condition 
which we call larjaigeal phthisis. That the constant movement 
to which the larynx is subject, plays an important part in the 
causation of laryngeal phthisis, is still further shown by the fact 
that the most frequent manifestation of the disease is seen in 
that portion of the organ which is subject to the most constant 
and restless motion, viz., the arytenoid cartilages and inter-ary- 
tenoid commissure, the special movements taking place in these 
being such as would naturally tend to aggravate and irritate an 
inflammatory condition ; the commissure being folded wpon it- 
self and squeezed as it were between the cartilages with each 
act of phonation and resi3iration. 

A larger proportion of cases of the disease occur in con- 
nection with, or subsequent to the development of pulmonary 
disease. The true explanation of this is, that the pulmonary 
phthisis is largely the cause of the laryngeal phthisis, not that 
the two are necessarily developed from one and the same cause. 
The majority of cases of lung disease are attended with more 
or less catarrh of the mucous membrane lining the larynx. 
This catarrh is aggravated by the constant motion to which the 



LARYNGEAL PHTHISIS. 287 

parts are subjected in plionation and respiration. The constant 
cough which attends the lung disease cannot but be an ad- 
ditional source of irritation, and besides this, the membrane is 
being constantly bathed by the discharges, often of a fetid and 
offensive character, which pass over it from below. If, now, 
the pulmonary disease be of such a nature as to lead to im- 
pairment of the general health, we have all the conditions 
favorable for the development of the affection under consider- 
ation, for I am convinced that impaired vitality is a most essen- 
tial factor in its causation. 

Primary laryngeal phthisis, if not arrested, leads to the de- 
velopment of pulmonary disease. It is generally said of these 
cases that the iDulmonary disease already exists, but is masked 
by the laryngeal disease, and cannot be detected by physical 
signs. It is easier to believe that the pain, constant hacking 
cough, loss of sleep, interference with proper nutrition by the 
painful deglutition, and the fetid discharges poisoning every 
breath of inspired air, all prominent symptoms of the laryngeal 
disease, must necessarily aggravate the previously existing state 
of impaired health, and eventually lead to the development of 
further disease, which fixes itself upon the organ most closely 
connected anatomically and physiologically with the one pri- 
maril}^ affected, viz., the lungs; the laryngeal disease acting 
as the direct cause of the lung disease. We thus have estab- 
lished a vicious circle, the one reacting upon the other, and 
both completing a picture of pain and suffering rarely exceeded 
in our experience. 

The influence of laryngeal ulceration upon the general 
health, is again very markedly evidenced by those cases in 
which a foreign bod}^, becoming lodged in the upper air-pas- 
sages, gives rise to ulceration, followed by greatly impaired 
health, with emaciation, and eventually death from this cause, 
or concurrent lung disease. 

Among the conditions under which laryngeal phthisis may 
develop are enumerated, tlie tubercular and scrofulous diathe- 
ses, malaria, and syphilis. The intimate anatomical and physio- 
logical connection between the larynx and lungs is sufficient 
to explain why a very large preponderance of cases of laryn- . 
geal phthisis occur in connection with the impaired state of 
health which attends chronic lung disease. Syphilis is in- 
cluded among the causes, and by this is meant more lU'operJy 



288 DISEASES OF THE LAKYT^X. 

what has been termed syphilitic asthenia, viz., that condition 
of markedly impaired health we sometimes meet with as the 
result of infection, in which all specific manifestations of the 
disease have disappeared. That in this condition laryngeal 
phthisis may develop, I entertain little doubt, having seen such 
cases, in which the progress of the disease and the character 
of the ulceration in no way resembled the more specific dis- 
ease, but presented all the features_ of the ordinary laryngeal 
phthisis as described farther on. 

Many writers, in treating of the disease; describe the first 
stage as one of anaemia of the larynx. This condition of anae- 
mia of the mucous membrane of the lar3aix is not a rare one, 
and while it may in many cases exist before laryngeal phthisis, 
and perhaps excite suspicion, yet it does not point directly to 
the disease, and presents no features by which we can, with 
any certainty, recognize the threatened danger. There is, there- 
fore, no sufficient reason for considering it a stage of the dis- 
ease. 

The fir d stage is that of pyriform thickening of the mucous 
membrane covering the arytenoid cartilages and inter-arj^tenoid 
commissure. This thickening is peculiar 
and characteristic. (See Fig. 115.) 

The contour of the cartilages is com- 
pletely masked and concealed by a thick, 
club-shaped swelling, while the commis- 
sure bulges out in such a manner as to 
present a rounded mass anteriorly, which 
^a^t;^^:^:iT^^- oftentimes interferes with the approxima- 
Skenlte.T''''^'''" ^^'''^'^'^ ^^^^^ ^^ ^^^^ cords, while at the same time 
it extends upward, so as to reach nearly to 
the level of the cartilages, and fills up the normal notch be- 
tween them. The mucous membrane is reddened throughout 
the larynx and presents a moist, boggy appearance, especially 
over the swollen arytenoids where it is covered with mucus or 
muco-pus. 

The second stage is that of infiltration of the epithelial coat 
of the mucous membrane. In this stage we first notice what 
constitutes a prominent feature of laryngeal phthisis, viz., an 
excessive cell-proliferation. There appears on the surface of 
the membrane a small, whitish-gra}^ patch, slightly raised above 
the surface, and seemingly an infiltration of its epithelial layer. 




LARYNGEAL PHTHISIS. 289 

This occurs, in tlie majority of cases, on the laryngeal face of 
the arytenoid commissure. Its next most frequent site is one 
of the ventricular bands, and then indifferently in other por- 
tions of the organ. These patches may present themselves 
singly when they may attain a considerable size, or they may 
present in groups. Their duration is very limited, as they 
rapidly run into : 

The third stage, which is the stage of fully developed ul- 
ceration. This change I have watched in several cases and 
have seen the grayish patch gradually change from an appar- 
ently quiescent state to one of active discharge ; the superficial 
layer of epithelium being thrown off and new cells being pro- 
duced, they gradually degenerate into pus-cells ; the surface of 
the formerly gray patch becomes 
yellow in color, the discharge be- ■^a ~~ ^ 

comes purulent in character and ^ ''^- 

the ulcerative action becomes es- |v 
tablished. The ulcer extends by '"^^"^ 
extending its margins and also by ^.- 

attacking and eroding the parts p,,. iifi.lscat'^;icerat.o„s of the 
beneath ; and the waste of tissue *'^^;^ f^^^ °^ laryngeal phthisis. (Mack- 
commences which gives name to 

the disease. The ulceration may be small, or cover a com- 
paratively large surface. It may be made up of a number of 
minute points of ulceration, as most frequently occurs when 
the disease attacks the epiglottis, or there may be several large 
ulcers distributed in different parts of the larynx. (See Fig. 
116.) 

In this stage we notice, more prominentl}^, the excessive cell- 
growth which characterizes the disease. While the destructive 
ulceration goes on we find developed, sometimes on the ulcer- 
ated surface, but more frequently on its margins, small, 
pointed, warty growths, which may be so extensive, as al- 
most to conceal and overshadow the ulcerative process. Thej^ 
are very soft, pliable, and easily removed. The error is some- 
times committed of picking them oft' with the forceps, but ex- 
])erieiice teaches the wisdom of letting them alone, certainly 
until the ulcerations have been entirely healed. 

During the second stage, often, but far more frequently du- 
ring the third stage, there may occur a development of the dis- 
ease of most serious import, in that it not only increases in a 
19 



290 DISEASES OF THE LARYJ^X. 

marked degree tlie sufferings and distress of the patient, but 
also renders the prognosis very much more grave. This con- 
sists in the occurrence of an acute follicular inflammation, in- 
volving the mucous membrane of the epiglottis, expending it- 
self mainly upon the follicles so richly distributed about the 
crest, or it may attack the arj^tenoids. Its onstit is character- 
ized by the sudden pouring out of an exudation into the folli- 
cles, of the same character, probably, as that which occurs in 
the second stage of the disease, as before described, but in the 
one case it infiltrates the epithelial laj- er of the membrane, while 
in the other it is deposited in and distends the follicles. It 
occurs with great suddenness, and without warning, a few 
hours often being sufficient for its development. 

An examination of the parts at the onset of this form of 
the disease shows the epiglottis swollen and the mucous mem- 
brane in a state of active, acute inflammation. The crest is 
rounded, thickened, and turban-shaped (see Fig. 117), and on 
the surface of the swollen membrane are seen minute project- 




FiG. 117. Via. 118. 

Fig. 117. — Turban-shaped thickening of the epiglottis, together with club-shaped thickening of the 
arytenoids in laryngeal phthisis. (Mackenzie.; 

Fig. 118. — General and destructive ulceration in the later stages of laryngeal phthisis, a large portion 
of the epiglottis having been destroyed. (Mackenzie.) 

ing points, thickly distributed, of a pearly white or gray color, 
and slightly clouded as if seen through a diaphanous covering. 
The appearance resembles very closely that of the tonsil in 
a state of acute follicular inflammation, in which the morbid 
condition is probably much the same, with the exception that 
in the case of the tonsils, the follicles being so much larger and 
more capacious, the projecting gray points are far more promi- 
nent. The subsequent progress of this form of the disease is 
marked by the bi-eaking away of the covering of the follicle, 
the purulent degeneration and discharge of its contents, and the 
formation of a minute point of ulceration at its seat, which, by 
a slow process, extends its margin until it coalesces with others, 



LARYNGEAL PHTHISIS. 291 

and finally we may have the whole crest of the epiglottis and 
a portion of its posterior face involved in a sluggish and slowly 
destructive process of ulceration (see Fig. 118), the surfaces be- 
coming clogged and covered with a dirty-looking grayish, mu- 
co-puriilent discharge. This condition constitutes what is 
usually termed the epiglottic form of the disease, and is un- 
questionably laryngeal phthisis, but whether what has been de- 
scribed as the first stage is one and the same disease with this 
form may be questioned by some. Having carefully observed 
a number of cases which, resisting efforts to arrest the disease, 
passed progressively through all the stages, I am convinced 
that they are one and the same disease, and, therefore, Avould 
urge the importance of recognizing this fact, and hence the im- 
perative duty of making every effort to arrest it in its early 
stages before the later and more intractable form of the disease 
has set in. 

The other appearances which we meet with are secondary, 
and dependent upon the ulceration, such as acute catarrhal 
and phlegmonous inflammation of the nmcous membrane lin- 
ing the larynx, and not involved in the ulcerative, action ; 
oedema of the loosely attached portion of the mucous mem- 
brane, as the ary -epiglottic folds and the lar3aigeal face of the 
epiglottis ; and perichondritis and necrosis of the cartilages. 

Subjectioe symptoms. — As the above described conditions 
develop, the subjective symptoms become prominent. These 
are pain, cough, difficult and painful deglutition, hoarseness, 
if the cords are affected, and aphonia, if the thickened condi- 
tion of the arytenoid commissure prevents their approximation. 

In the first stage the symptoms are not prominent, there is 
an irritated condition, with a sense of pricking or tickling in 
the throat, and there may be some pain in swallowing, due to 
l^ressure on the filaments of nerves distributed in the swollen 
parts. As the disease progresses we have the severe and 
oftentimes exquisite pain due to the pressure to which the parts 
are subjected in the movements of res])iration, phonation, and 
especially in deglutition. If the epiglottis is involved, the sub- 
jective symptoms become greatly aggravated, the pain and 
difficulty in swallowing become oftentimes most acute, and 
even the movements of the larynx, in respiration or talking, 
become a source of extreme suffering. The food is oft(Mi r(\gur- 
gitated, and any attempt to swallow is made with reluctance, 



292 DISEASES OF THE LARYNX. 

on account of tlie exquisite pain caused by tlie act, the addi- 
tional element of pain being due to the mechanical pressure of 
the bolus of food upon the inflamed surface. 

Diagnosis. — In the later stages of the disease this is not 
difficult. The disease above all others with which it may be 
confounded is tertiary syphilis of the larynx, in which we 
have the rapidly destructive ulceration, the sharp-cut edges, 
the excavated surface covered with yellow pus, the absence of 
the warty growths which characterize phthisical ulcers, and 
esj)ecially the areola of red angr^^-looking mucous membrane 
which surrounds it, with the general condition of the patient, 
showing no marked evidence, usually, of impaired nutrition. 
In laryngeal phthisis, on the other hand, we have an essen- 
tially chronic process of ulceration ; the edge of the ulcer 
ragged and irregular, but not excavated ; tlie surface of the 
ulcer not markedly depressed, and oftentimes raised above the 
surrounding parts by the excessive cell-proliferation ; the ab- 
sence of the inflamed areola ; and the general condition of the 
patient, always in bad health, and, in a large majority of cases 
this due to commencing or existing pulmonary disease ; add to 
this the subjective symptom of pain which is characteristic of 
laryngeal phthisis almost without exception, and which is not 
prominent in syphilis, and the differential diagnosis is made 
comparatively easy. With lupus carcinoma, and the various 
neoplasms which are met with in the larynx, the disease need 
rarely be confounded. 

But while the diagnosis is not difficult in the later stages, 
the question becomes an extremely important one, whether we 
have any certain means of recognizing the disease in the flrst 
stage, for I am confident that when early recognized it is in 
our power, in certainly a very large majority of cases, to arrest 
its farther progress. The condition described as the first stage 
of the disease, viz., the club-shaped arytenoid cartilages and 
the p3aiform thickening of the commissure, is believed to be 
pathognomonic of laryngeal phthisis and is found in no other 
disease. This condition I have never yet seen except in this 
disease, or where the diagnosis has not been fully confirmed by 
the subsequent history of the case or by other confirmatory 
symptoms elicited at the time. 

Prognosis. — We are usually taught that an improvement 
in the pulmonary symptoms is attended by an aggravation of 



LARYNGEAL PHTHISIS. 293 

tlie laryngeal symptoms, and vice mrsa. This is but a partial 
statement of the case. In a given case of laryngeal phthisis, 
occurring in connection with chronic pulmonary disease, a 
sudden aggravation of the lung disease may be attended with 
an apparent amelioration of the subjective laryngeal symp- 
toms. How this is so it is difficult to understand. Possibly 
the increased morbid action in the one organ may act as a de- 
rivative from the other, but that anything more than tempo- 
rar}^ relief of subjective symptoms occurs is improbable ; and 
the same may be said of the converse. But these changes and 
interacting improvements occur entirely outside of, and inde- 
pendently of au}^ therapeutic measures. In my experience an 
improvement in the laryngeal ulceration which is due to direct 
local treatment, is not followed by or attended with any ag- 
gravation of the lung trouble. On the contrary, the general 
condition improves, the lung symptoms are ameliorated, and 
in several cases I have detected unquestionably very decided 
improvement in the lung disease as shown by physical ex- 
amination. Certainly in no case has it been possible to trace 
any direct connection between an aggravation of the one 
disease and an improvement in the other. In the earlier 
stages the disease is curable, in probably the majority of 
cases ; and even after the occurrence of extensive ulceration 
and destruction of tissue I have seen cases recover. The 
occurrence of the follicular ulceration, described as attacking 
the epiglottis, renders the prognosis very grave ; and in the 
majority of cases the only hope is to relieve somewhat. This 
can be accomplished in most cases. 

Treatment. — This consists of four steps, which are regarded 
as of importance : 

First. — The thorough cleansing of the parts preparatory 
for the more special application. 

Second. — The application of such mild astringents, altera- 
tives, or resolvents, as may be indicated. 

Third. — The application of an anodyne to relieve pain or irri- 
tability, and to correct irritation caused by the previous reme- 
dies. 

Fourth. — The application of iodoform as a specific in its 
action on ulcerations of mucous membranes. 

The cleansing is best accomplished by one of the cleansing 
solutions given in the Appendix, preference being given to the 



294 DISEASES OF THE LARYNX. 

lirst. These are best applied by the Sass spray tubes with the 
compressed air apparatus, the pressure being about fifteen 
pounds. The application should always be grateful to the 
patient, and if there is any pain or irritation caused by it, the 
solution used should be reduced in strength, or changed. Care 
should ahvays be exercised, of course, to avoid wearying the 
patient. If nausea or vomiting is caused the sitting should ter- 
minate for a time. After the parts are thoroughly cleansed, an 
anodyne solution should be used. This I regard as highly es- 
sential. Of these a live- to ten-grain solution of morphine may 
be used, with the addition of soda3 carb., or potass carb., to 
give it an alkaline reaction. A small portion of mucilage aca- 
citTB added may increase its soothing effect. The next step in 
the treatment consists in the application of an astringent. In 
the order of preference, there may be used : tannin, gr. x. — 33., 
argenti nitrat., gr. j. — 3 J., zinci sulph., gr. iv. — 3 J. ; the selec- 
tion of the special astringent being governed somewhat by the 
effect and tolerance. Finally, there should be applied iodoform 
to the surface of the ulcer. This is used for its specific action ; 
it is easily borne, rarely gives pain, and its effect in many cases 
is most satisfactory. The formula I generally employ is as 
follows : 

I^ . Morphije gi'- x. 

Tannin 3 ij. 

lodoformi 3 vi. 

M. 

Sometimes the saturated solution of iodoform in ether 
may be used, tti, xl. — | j., but the powder is generally prefer- 
able. This application is made with the powder-blower shown 
in Fig. 47. 

The diseased parts in laryjigeal phthisis are extremely irri- 
table and exquisitely sensitive, and the object should always 
be kept in view of accomplishing the treatment with as lit- 
tle irritation as possible. If, then, our remedies can be de- 
posited on the parts, without the instrument touching them 
by which they are conveyed, it is an end to be desired. The 
spray and powder insufflator accomplish this ; the brush, the 
sponge, and the probe necessarily touch the diseased parts and 
are liable to do harm. I long ago abandoned their use from 



LARYNGEAL PHTHISIS. 295 

this consideration. Pursuing tlie plan of treatment indicated 
above, it is almost an invariable rule that the applications are 
not only well, but gratefully borne, and followed by immediate 
relief to the subjective symptoms. 

The above plan of treatment is for the stage of ulceration. 
The earlier stages of the disease should be treated in the same 
manner, with the omission of the use of iodoform, which, as 
stated above, is only used for its specific action in ulceration. 
Inhalations, as a rule, are useless, or of very limited efiicacy 
in laryngeal phthisis. The volatile remedies, which may be 
applied in this manner, exercise so little of curative or con- 
trolling influence on the disease that their use is a waste of 
time. Those remedies which are of most benefit by their local 
action cannot be volatilized. Lupulin, opium, cannabis indica, 
conium, and other sedatives are of some benefit in allaying 
pain, but it is limited. Benzoin, turpentine, creosote, and 
iodine are, as a rule, too irritating. Among the instruments 
in most frequent use, in the treatment of laryngeal phthisis, 
is the steam atomizer. This is an ingenious and attractive lit- 
tle instrument, but, nevertheless, an instrument of mischief in 
this disease. It is often desirable that the patient should have 
some method of using medicated solutions during the intervals 
of treatment, and for this purpose there is nothing better than 
the atomizer shown in Fig. 63. The fiuid for use may be the 
carbolized alkaline solution given as a cleansing solution. To 
this may be added a sedative, if indicated, such as a drachm 
of Magendie's solution to the ounce. 

In the earlier stages of the treatment it is desirable that the 
patient be seen generally .as often as every second day, but 
that should be governed by the duration of the relief which is 
given at each sitting. At the commencement it will often be 
necessary to give dai]}'' treatment, but if the progress of the 
case be favorable it will soon be necessarj^ to repeat the treat- 
ment but once a week, or even in two weeks. 

These measures failing to relieve or arrest the progress of 
tlie disease, the question of tracheotomy arises as a remedial 
measure in the earlier stages of tlu' disease, before oedema with 
dyspnoea have occurred, which, ol" course, may imperatively 
demand the operation. The consideration which operates in 
favor of tracheotomy is the entire rest thereby securcMl to the 
larynx from the movements of phonation and respiration, thus 



296 DISEASES OF THE LAEYNX. 

putting the parts in the most favorable condition to recover. 
Tlie consideration which operates against tracheotom}'" is the 
total ablation of a large and important part of the upper air- 
passages, by which the inspired air is rendered warmer, moist- 
er, and cleaner before it reaches the lungs. This consideration 
should never be lost sight of, and if the objection can be ob- 
viated by proper measures, which will occur to any one, it 
would seem that we have a resource which might more fre- 
quently be adopted. The operation is a simple one, and is 
rarely attended with any bad results due to the operation it- 
self — such as shock, excessive hemorrhage, etc. 

In closing, there are certain conclusions which I would sug- 
gest as being well grounded. These are : 1st, laryngeal phthisis 
may develop from a simple catarrhal inflammation, if there ex- 
ists an impaired state of health from any cause; 2d, the pro- 
gressive stages are catarrhal infiltration, catarrhal ulceration, 
and follicular inflammation ; and tubercle, as a rule, plays no 
part in its primary causation or development ; 3d, the disease 
is far more amenable to treatment than is generally taught, es- 
pecially if treated in the earlier stages ; 4th, tracheotomy is 
justiflable as a remedial measure, when local remedies fail to 
relieve, and before it is demanded by dyspnoea from inflamma- 
tory stenosis. 



CHAPTER XVIII. 

SYPHILIS OP THE LARYNX. 

Local conditions due to tlie syphilitic poison may develop 
in the larynx at any time from the fourth or fifth week after 
the primary infection to the end of life. Those affections 
which occur within one or two years after infection, we are ac- 
customed to regard as belonging to the secondary stage of the 
disease. In this period w^e meet with syphilitic catarrh of the 
larjnix and mucous patches. Among the affections which are 
classed under the head of tertiary manifestations are chronic 
catarrhal laryngitis, superficial ulcerations, and deep ulcera- 
tions, with their resultant necrosis of cartilage and deforming 
cicatrices. This division into two groups of secondary and 
tertiary syphilis is somewhat arbitrary, and we not infre- 
quently meet with syphilis of the larynx which we cannot 
with certainty assign to either the secondary or tertiary stage, 
and our decision will be based mainly on the clinical history 
of the case. Subacute catarrh invariably belongs to the second- 
ary stage, while mucous patches or superficial ulcerations may 
be met with either early in the history of the disease or very 
late, w^hile the chronic laryngitis of syphilis also may belong 
to the clinical historj^ of secondary or tertiary syphilis ; in the 
majority of cases, however, the latter is a tertiary manifesta- 
tion of the disease. 



Subacute Cataerii of the Larynx m Syphilis. 

This affection generally makes its appearance from six 
weeks to three months after the primary sore, and consists in 
the development in the mucous membrane of the larynx of a 
catarrhal inflammation acute in character, yet of a mild type, 
presenting much the same appearances as an idiopathic sub- 



298 SYPHILIS OF the lakynx. 

acute catarrhal laryngitis, and from which it is, as a rule, ex- 
tremely difficult to distinguish it. Laryngeal disease, however, 
is very liable to make its appearance in connection with the 
eruption on the skin, so that the clinical history oftentimes 
will aid the diagnosis. In addition to this there are certain ap- 
pearances on laryngoscopic examination which are frequently 
met with, and which characterize the syphilitic laryngeal 
catarrh in contradistinction from the non-specilic affection. In 
place of the uniform, broad, rosy tint, which is seen in the lat- 
ter affection, there will be noticed, if the affection is specific, 
that the membrane is of a deeper color, with a tint which verges 
somewhat on a purplish hue, and also that the discoloration is 
not perfectly uniform, but that it is apt to be somewhat mot- 
tled, not unlike the eruption of roseola on- the skin. Aside 
from this deepened color and mottled appearance we have no 
means of distinguishing the specific from the non-specific form 
of subacute laryngeal catarrh. The subjective symptoms are 
identical in the two affections and may be briefly summarized 
as a more or less complete loss of voice, with a slight sense of 
irritation or tickling in the throat, with a cough of a stridulous 
character, together with a moderate excess of secretion. 

Treatment. — The treatment of this affection consists in the 
administration of mercurials under the same rules which gov- 
ern the' management of any case of secondary syphilis. In 
addition to this it is well that some local treatment should be 
resorted to, to limit and control the local affection, which may 
lapse into a chronic laryngeal catarrh, which is liable to persist 
after the systemic disease has been cured. The local treatment 
should be the same as that of a subacute laryngitis. 



Mucous Patches in the Larynx. 

This manifestation of syphilis, though undoubtedly an ex- 
tremely rare one, unquestionably is met with occasionally in 
the larynx. It may occur, as do mucous patches in other por- 
tions of the respiratory tract, at any time, from three months 
to five or ten years after the primary sore, though, as a rule, it 
is met with in the early history of the disease, and therefore 
should be classed among the secondary manifestations. I have 
never seen but two cases in which I have felt convinced of the 




MUCOUS PATCHES IN THE LAEYNX. 299 

presence of a raucous patch in tlie larynx. In each of these 
cases it occurred on the false cord. Other cases have been re- 
ported of mucous patches -on the true cords, the arytenoid 
commissure, and epiglottis. The reported cases, however, are 
so few^ that it is difficult to generalize from them as to the point 
or part of the laryngeal cavity vs^hich is the most frequent site 
of their development. When seen they present the same ap- 
pearance as mucous patches found in any other portion of the 
mucous membrane of the upper air-passages, viz., the bluish- 
white opaque infiltration of the membrane, circumscribed in 
extent and elevated somewhat above the surface (see Fig. 119). 
On account of the functional activity 
which chai'acterizes the larynx, and the 
necessary irritation to which any morbid 
process in the organ is subjected, the 
tendenc}^ to ulceration which character- 
izes the mucous patch in other portions ^^^^ ^lo h on the 
of the air-passages, is, of course, mark- [ZtLnz'i) ' " '''''°""- 
edly aggravated in this region. Hence, 

it becomes by no means improbable that a mucous patch may 
very frequently be the starting-point of a superficial ulcer- 
ation, and that therefore many of these cases which only come 
under observation after the ulcerative process has set in, may 
have had their origin in this manifestation of the disease. 

The symptoms of a mucous patch are, a sense of irritation 
in the larynx, with tenderness on pressure externally, painful 
deglutition more or less well marked, with impairment of voice 
dependent somewhat on the location of the patch. 

Treatment. — In addition to general treatment, active local 
measures should be resorted to for the destruction of the 
patch ; tills is the more especially indicated if, as has been 
suggested, its tendency is to lapse into ulceration.- The patch 
should be toucliecl dail}^ at the beginning, with the solid stick 
of nitrate of silver. This is best accomplished by fusing a 
small jjortion of the caustic on the end of a bent probe, and 
cariying it down to the part by the aid of the laryngoscopic 
mirror. The disappearaiK-c ol" the disease is iinicii aided by 
the application of iodoform to the cauterizixl suitace. The 
combination of these two remedies has proved more effective 
in my hands, in the management of tliese jiatchcs, tlmn nny 
other, although either remedy used singly will ))c roiind of 



300 SYPHILIS OF THE LARYNX. 

miicli benefit. Occasionally, in place of the solid stick, a solu- 
tion of the caustic may be used of the strength of gr. xl.— 3 j- 
to I j. This may be applied by means of the cotton pellet and 
the laryngeal probe. Other destructive agents, as nitric acid, 
acid nitrate of mercury, chromic acid, etc. , are probably equal- 
ly efficacious ; but none of them afford the same convenience 
of manipulation as does the nitrate of silver. 

It is unnecessary to add that, in connection with local treat- 
ment, the internal administration of mercury is of the utmost 
importance, and that it should be commenced immediately, and 
followed up actively and persistently in this oftentimes most 
troublesome manifestation of syphilis. Equally true is it, also, 
that internal medication is inadequate, as a rule, to cope with 
these patches without also local destructive agents. 



Cheonic Catarrhal Laryngitis of Syphilis. 

This manifestation of syphilis in the larynx makes its ap- 
pearance in the later stages of the disease. It might well be 
designated as laryngitis deformans of syphilis— a name which 
describes the disease more perfectly than the one used above, 
and is the one which would be adopted but for a natural hesi- 
tation in introducing a new name to our nomenclature, which 
is already overburdened by its many and oftentimes confusing 
terms. The disease is a chronic inflammation of the mucous 
membrane lining the larynx, due to the syphilitic poison, and 
characterized by certain morbid processes, which produce 
very serious deformity of the organ with impairment of func- 
tion, yet without necessarily the occurrence of any ulceration 
or other destructive process. It is generally a tertiary lesion, 
occurring, from five to fifteen years after the primary sore. It 
commences with an apparently simple sore throat, with moder- 
ate congestion of the mucous lining of the larynx, and gradu- 
ally progresses until there may eventually arise, as the result 
of the infiltration and thickening of the membrane, and en- 
croachment on the laryngeal cavity, a condition of stenosis 
which may involve extremely grave consequences, unless re- 
lief is speedily afforded. In the early stages the affection is 
apparently a simple laryngeal catarrh ; but it is more than 
this, for a close inspection will reveal the fact that the morbid 



CHROlSriC CATAEEHAL LAEYNGITIS OF SYPHILIS. 301 

process lias already commenced in tlie deeper tissues of tlie 
membrane, with more or less congestion of its surface. 

This process, in the deep layer, consists in a deposit of glan- 
dular and connective-tissue elements which, progressing by 
slow degrees, produces the deformities which characterize the 
later stages of the disease. This deposit or thickening does not 
occur evenly, but seems to manifest itself in one part of the 
organ more than in another, producing irregular and somewhat 
nodular elevations, scattered throughout the membrane. These 
elevations do not give rise to rounded, tumefied swellings, but 
merely to a somewhat rugged condition of the lining of the 
larynx. The process is essentially a chronic one, and develops 
very slowly, months, or even years, being required for the 
manifestation of the graver symptoms. It does not seem to 
confine itself to any one portion of the larynx, but diffuses it- 
self throughout the whole cavity, yet being more active in one 
portion than in another. If any portion of the organ is more 
frequently affected than another, it is generally one of the false 
cords or of the arytenoid cartilages, though occasionally we 
may find it attacking the epiglottis alone, while the parts below 
remain comparatively free ; though when this occurs we find, 
as a rule, that the swelling and infiltration is not symmetrical, 
but will show itself more markedly on one side, and this still 
of a somewhat irregular outline. 

In a proportion of cases the prominent characteristic is its 
disposition to confine itself to one side of the larynx, or rather 
to develop on one side to a marked extent, while the opposite 
side remains comparatively unaffected or affected to but a 
slight degree. The mucous membrane does not present the 
bright, rosy hue of acute catarrhal inflammation, nor the char- 
acteristic discoloration of chronic catarrhal disease, but pre- 
sents a deep, red color, verging on a purplish aspect. It is 
smooth and rounded, with an appearance of tension, and yet 
not the tension of oedema or ^phlegmonous inflammation, but 
with a thoroughly opaque aspect. It is moist and glistening, 
and covered with thin, frothy mucus. 

As this condition develops in the larynx the subjective 
symptoms become prominent. TJie voice is very early affected, 
but in a peculiar manner, it is not lost entirely nor is it a hoarse 
voice, but it takes on a rougli, rude, raspisli character, which 
is peculiar to this form of syphilitic laryngitis. This is espe- 



302 SYPHILIS OF THE LARYNX. 

ciall}' marked when one or both of the cords are involved in tlie 
morbid process. There is pain referable to the fauces, a sense 
of rawness, or irritation in the throat, with difficulty in swal- 
lowing, more or less well marked according to the parts affected. 
If the epiglottis is involved the pain is more prominent, but it 
is a dull pain, never of a lancinating character, but more of a 
sense of discomfort. This symptom is always present to an 
extent, with more or less tenderness on external pressure, but 
is never present to the extent we lind it in the ulcerative la- 
rjmgitis of syphilis, or in laryngeal phthisis. There is more or 
less cough present, of a hackhig character, but this is not a 
prominent feature of the affection. 

Examination. — On examination with the laryngoscopic mir- 
ror, the first and foremost feature that will be noticed is a lack 
of symmetry in the larynx, and the membrane lining it will be 
seen of a dark red, injected color, covering an apparent tume- 
faction. If the disease involves one of the false cords, this will 
be seen to project more or less from its normal site, and the true 
cord of that side will be partialh' masked, or completely hid- 
den. If one of the arytenoid cartilages is involved, it will stand 
out prominently and apparently overtoj) its fellow. If the epi- 
glottis is involved, it will be noticed that it is contorted or 
twisted out of shape, its crest will be swollen and somewhat tur- 
ban-shaped, but still covered by the discolored, opaque mucous 
membrane. When the cords are involved, on account of the ex- 
treme thinness of the membrane, the thickening will be slightly 
marked, but still noticeable to the extent of interfering seriously 
with their free vibration. The character and extent of the swell- 
ing of the cords will be still more noticeable, and more easily es- 
timated b}^ a close examination of their free borders, which will 
be seen to have lost their straight line, and will present a some- 
what scalloped edge, but still irregular, and with a slightly 
ragged aspect. The motion of the cords will not be necessarily 
interfered with, except mechanically. If the arytenoids and 
commissure are involved, the free motion of the cords will be of 
course impaired according to the extent of the swelling. This 
may exist to such a degree as to produce almost complete ar- 
rest of motion, in which case a mistake in diagnosis might 
easily be made. A careful inspection, however, will enable the 
observer to estimate, with precision, how far the apparent par- 
esis is due to the mechanical obstruction to the free movement 



CHEONIC CATAEEHAL LAEYNGITIS OF SYPHILIS. 303 

of the cords, and also to detect that there is unquestionable 
movement in the parts, and that of a symmetrical character. 
This, of course, would not exist if there were genuine paralysis, 
as in this case the loss of movement would be complete, and in 
a majority of cases unilateral. 

If the disease has advanced to the extent of producing in- 
terference with respiration, as it does in ma.ny instances, the 
examination will show the entrance into the larjmgeal cavity 
marked!}^ narrowed and encroached ui^on by its thickened lin- 
ing membrane, the point of stenosis being generally at the 
upper orifice of thelarjnix, lying between and produced by the 
swollen false cords and epiglottis. 

Diagnosis. — Even to one familiar with laryngoscopic exam- 
inations, the recognition of this disease is by no means always 
an easy matter. The absence of ulceration, which a close in- 
spection will reveal, necessarily excludes laryngeal phthisis and 
also the ulcerative diseases of the larynx due to syphilis. The 
only diseases with which it may be confounded are chronic 
catarrhal laryngitis and tumors. Occasionally the thickening 
of the mucous membrane which attends the affection under con- 
sideration may so localize itself as to present the appearance of 
a tumor. This is especially true when it is confined to one of 
the false cords. A close inspection, however, and study of the 
part ought to enable the observer to differentiate between the 
localized tumor and the diffu.sed infiltration of the mucous 
membrane in the specific affection. Chronic catarrhal laryn- 
gitis, with congestion and a moderate degree of swelling, always 
displays a perfectly uniform and symmetrical injection of the 
membrane ; whereas, in the disease we are considering, perfect 
symmetry or uniformity of the tumefaction rarely if ever exists. 

Prorjnosis. — The invasion of the larjnix by any of the later 
manifestations of syphilis, or the establishment of one of the 
earlier lesions, by its fixing itself upon the part and lapsing 
into a chronic state, I regard as one of the gravest and most un- 
fortunate of accidents ; hence the early recognition of the dis 
ease becomes of the highest importance. This can only be 
attained by the use of the laryngoscopic mirror. If recognized 
and correctly treated both internally and locally it is fairly 
amenable to treatment, hi I Ik- later stages, however, when the 
larynx has become disoiganized, and its function seriously in- 
terfered with as shown by the ]))X)minent subjective symptoms 



304 SYPHILIS OF THE LAKYNX. 

of impairment of voice, etc., with the appearances on examina- 
tion of the thickened and infiltrated condition of the membrane 
extending throughout the cavity, involving maiiied deformity, 
it becomes simpl}^ a question of arresting the further develop- 
ment of the disease. The restoration of the voice, of course, 
is impossible, but the prevention of further morbid action may 
be hoped for by active measures. 

Treatment. — This consists in the administration of general 
remedies, under the rules which govern the management of con- 
stitutional syphilis. Iodide of potassium, in combination with 
muriate of ammonia, should be given in full doses as follows : 

5^. Potass, iodidi 3 vi. 

Ammonite mur 3 iij. 

Aqufe 3 iv. 

M. Sig. — One teaspoonful three times a day. 

The dose of iodide of potassium should be increased each 
third day b}^ the addition of one drachm to the ounce of the mix- 
ture. This should be followed up for two or three weeks, when, 
in addition to the above, biniodide of mercury should be ad- 
ministered, simply adding two grains of the mercurial salt 
to the mixtiire. This should be given for from four to 
six weeks or longer, when, as a rule, the administration of 
the potash should be discontinued. If marked benefit has 
resulted from its exhibition well and good, but if no result has 
been obtained its future administration is probably useless, 
and the mercury alone should be continued from twelve to 
eighteen months. The iodide of potash should be abandoned 
for two reasons : first, its tendency to produce congestion of the 
mucous membrane of the upper air-passages, thereby increasing 
the sufferings of the patient ; and secondly, on account of the 
deleterious effects on the kidneys attending its long-continued 
administration. In addition to .the internal administration of 
mercur\^, mercurial vapor baths may be given occasionally, 
with benefit, or inunctions of the ointment. The above plan 
of treatment is the one I have usually pursued, but of course 
in each case the administration of internal remedies at the 
hands of the physician may be governed by his best judgment 
as to their immediate effect. In addition to the general treat- 
ment, topical measures should be resorted to for the control 



CHRONIC CATARRHAL LARYNGITIS OF SYPHILIS. 305 

of the local morbid process. These should consist in the daily 
application to the laryngeal membrane of such remedies as 
exert a specific influence in reducing the swelling of the parts 
and limiting the extension of the disease. In the application 
of these remedies I still entertain a decided preference for the 
use of atomized fluids, applied by means of the compressed air- 
apparatus, Fig. 65, or the hand-ball atomizer, Fig. 61. In the 
absence of these or any means of using fluids in the state of 
atomization, resort may be had to the use of a sponge-holder 
such as that shown in Fig. 53, or the pellet of cotton wrapped 
firmly on a probe. 

Before making any application, the diseased surface should 
be thoroughly cleansed by the use of one of the cleansing solu- 
tions given in the Appendix. Having thoroughly removed the 
mucus that covers the diseased membrane, there should be ap- 
plied one of the following solutions, in the order of preference : 

1^ . Hydrarg. bichloridi gr- ij- 

Morphise sulpli gr. iv. 

Glycerin® 3 j. 

Aquae 3 j. 

M. 

3 • Zinci chloridi gr. vi. — x. 

Morphise sulph gr. iv. 

Aquse sj- 

M. 

IJ. Argenti nitrat gr. v. — xv. 

Aq. ext. opii gr. vi. 

Aquse 3J. 

M. 

The local action of the morphia or opium I regard as of es- 
pecial value in all of the graver and more painful affections of 
the larynx. They not only serve to allay irritation, but seem 
to exercis(3 either a direct curative effect on the part, or to aid 
in a marked manner the efficacy of the other local remedies 
used. They may be used as in the above prescriptions, or even 
in stronger solutions. 

These applications should be repeated daily under the direc- 
tion given for making laryngeal applications, and should not 
20 



306 SYPHILIS OF THE LARYNX. 

only be attended witli immediate relief, but should alwaj's be 
borne gratefully by the patient. As the treatment progresses, 
however, the applications may be made with less frequency, 
twice a week, once a week or even less being sufficient. It has 
been said in regard to local treatment of syphilitic disease of 
the larynx, that little or nothing is to be accomplished by it, 
but that the main reliance should be on internal medication. 
Of course local treatment will be of scant avail unless com- 
bined with internal medication ; but that nothing is to be ac- 
complished by topical applications is a broad statement, and 
one not to be entertained. Very much more can be accom- 
plished by active local treatment, combined with internal medi- 
cation, not only in the arrest of the further progress of the 
affection, but in the rapid removal of the existing morbid con- 
ditions, than can be expected by the administration of internal 
remedies alone. Hence, in the management of a disease so 
grave in its possible results as this form of syphilitic laryngitis, 
the whole duty of the ]3hysician has not been done unless the 
patient shall receive the full benefit of both internal and local 
medication. 



rLCERATIVE LARYNGITIS OF SyPIIILIS. 

Among the more frequent manifestations of syphilis in the 
larynx is that of ulceration, characterized by a more or less 
rapid and progressive loss of tissue. As a rule it belongs essen- 
tially to the tertiary stage of the disease, though we may occa- 
sionally meet with it in the earlier epoch or secondary stage. 
It manifests itself in two distinct forms, which we may desig- 
nate as superficial ulceration and deep ulceration, from the 
more striking characteristics of each. The superficial ulcer 
belongs more frequently to the earlier stages, while the deep 
ulcer is essentially a tertiary lesion. 

Superficial Ulcers of the Larynx ix Syphilis. 

This consists in the development in the mucous membrane 
of the larynx of an ulcerative process which confines itself 
mainly to the surface layer of the mucous membrane. It is 
somewhat limited in extent, and not characterized by any 



SUPERFICIAL ULCEHS OF THE LARYN^X 11^ SYPHILIS. 307 

marked destruction of tissue or rapidity of extension. In 
many cases probably it is due originally to a mucous patch, 
which, under the influence of locality, rapidly degenerates 
into an ulcerative process ; for we recognize in all morbid pro- 
cesses in the larynx the unfavorable influence of the constant 
motion to which the parts are subjected in its different func- 
tions of deglutition, respiration, and phonation. This may 
explain the fact that the mucous patch is so rarely seen in 
the larj^nx, for when such manifestation does occur, owing to 
the constant irritation to which it is subjected in that local- 
it3^, it so rapidly degenerates into an ulceration that when it 
comes under observation of the physician the mucous patch 
has disappeared and the superficial ulcer has taken its place. 
The superficial ulcer may, without question, also develop in the 
lar3mx as a local manifestation of the blood disease, without 
the intervention of the mucous patch. From what has been 
said it will be easily inferred that this manifestation of syphilis 
belongs to the secondary period, and yet we oftentimes find its 
appearance delaj^ed for years after the primary sore. Without 
assigning it specifically to either secondary or tertiary syphilis 
it is suflicient to state that, as a rule, within three or four years 
after the primary lesion, but occasionally from eight to ten 
years after, we meet with the simple ulceration of the surface 
layer of mucous membrane which we designate as the superfi- 
cial ulcer of laryngeal syphilis. Its most frequent site is on 
the false cords, and generally on their inner border. It occurs 
also not infrequently on the arytenoid commissure, and more 
rarely on the ary-epiglottic folds and face of the epiglottis. 
Occasionally we meet Avitli it on the vocal cords themselves. 
It makes its appearance as a small, rounded erosion on one of 
the parts above named, which extends very slowly, still pre- 
serving its regular outline, and rarely spreads over any great 
extent of surface. Its surface is of a bright yellow color and 
covered with thick creamy pus. Its edges are flush with the 
mucous membrane surrounding the ulcer, and rarely, if ever, 
depressed below its surface. The centre of the ulcer, however, 
is slightly depressed, sloi:)ing upward to the level of the mucous 
membrane surrounding it. In its extension it assumes an oval 
shape and extends longitudinally with the antero-posterioraxis 
of the larynx, as along the false cords and ary-epiglottic folds 
from before backward. The mucous membrane sun-ounding the 



308 SYPHILIS OF THE LARYNX. 

nicer is somewlmt reddened, presenting a deep rosy tint, having 
a faint bued areola, which, however, is not to be confused with 
the fiery red, angry looking areola of the mucous membrane sur- 
rounding the deep-seated ulcer to be described. The contrast 
]between the ulcerated surface and the surrounding membrane 
is well shown in Fig. 120. There is a considerable discharge of 
bright yellow pnsfrom the surface of the nicer, mingled with a 
moderate amount of ropy mucus, discharged from the nmcous 
membrane of the surrounding parts. When this form of ulcer- 
ation occurs on the vocal cords its appearance is greatly modi- 
fied b}^ the extreme thinness of the mucous membrane covering 
them and its scant supply of blood-vessels. Owing to these 
causes the prominent aj^pearances, on in- 
j.-"*^"^^-* spection, are so modified that the ulcera- 

^/^^s, \ tive action may easily be overlooked unless 

<Cl'^J ^^ careful inspection is made. It generally 

makes its appearance on the upper surface 
of the cord and near its free border. Oc- 
casionally it may extend over the edge of 
Fig i2o-Thevupp,ficiaiui- q^q cord, lu whlcli case, being seen in out- 

cer of larj ngeal s^ phihs on the ' ' O 

fMackSmeT °^ *^^ ^'''^^°"'*' ^'^^'^^ ^^ ^^ more easily recognized. The 
mucous membrane being, as before re- 
marked, extremely thin, the ulcerative process involves more 
nearly its entire thickness, and we recognize the small, rounded 
spot on the cord of a somewhat pale yellow color and faintly 
irregular or jagged outline, and surrounded by an areola, limit- 
ed in extent, of faintly injected blood-vessels. The color of the 
ulcer stands in no marked contrast with the mucous membrane 
surrounding it, but a close inspection will reveal it as an un- 
doubted ulcerative process. Its surface is somewhat depressed 
below the surrounding parts and secretes a small amount of 
muco-pus. 

Symiytoms. — The subjective symptoms which attend the de- 
velopment of this form of ulceration are not prominent. There 
is a sense of discomfort or rawness, occasional complaint of 
which is referred to the larynx, with more or less impairment 
of voice and occasionallj^ difiicult or painful deglutition. The 
symptoms, with reference to the voice, mainly depend on the 
localit}^ of the ulceration ; if this occurs on the vocal cord the 
voice becomes rough and rasping in character, and markedly 
lowered in pitch; if, however, the false cords or epiglottis is 



SUPEEFICIAL ULCEES OF THE LAEYNX IN SYPHILIS. 309 

involved the voice is simply somewhat husky ; if the commis- 
sure is involved the voice becomes aphonic, in consequence of 
the mechanical interference with the proper closure of the cords. 
If the morbid process locates itself on the epiglottis or upon 
the arytenoids there is apt to be more marked pain in swallow- 
ing. There may be some tenderness on external pressure over 
the thyroid cartilages, but this is never marked. In general, 
it ma}^ be said, however, that all the above symptoms may be 
prominently present, or so slightly manifested that the diag-. 
nosis will only be made on careful laryngoscopic examination. 
The diagnosis will be comparatively easy in the majority of 
cases, if the assertion already made is true, that ulceration of 
mucous membrane is not the very common occurrence it is by 
many believed to be, but is only due to some profound blood- 
condition ; hence these slighter forms of ulceration are only met 
with, as a rule, in syphilis and laryngeal phthisis. The differ- 
ential diagnosis between syphilitic ulceration and laryngeal 
phthisis will be aided largely by the clinical history of the case ; 
as between the disease under consideration and the third stage 
of laryngeal phthisis, described on page 289, the points of dif- 
ference are not markedly prominent as regards the ulcerative 
process itself, but in laryngeal phthisis there will be found the 
club-shaped arytenoids, the chronic laryngeal catarrh, together 
with the seriously impaired general health which characterizes 
that disease ; these conditions are not found in syphilis. In the 
chapter on laryngeal phthisis, one of the causes alluded to as 
leading to that affection was syphilitic asthenia. It would seem 
that in the two affections there were many points of confusion, 
as in each case there is the previous syphilitic history followed 
by the development of an ulcerative process in the larynx 
whose characteristics are similar; but in the case of laryngeal 
phthisis due to syphilis or syphilitic asthenia, as it has been 
called, there is the clinical teaching, which a close observation 
of the case would point out, of the future progress of the case 
toward destructive ulceration ; whereas, in syphilis, wejiave the 
same clinical history, the similar ulcerative process, but no 
marked impairment of health, and no progressive destruction 
of tissue ; with the subjective symptoms of laryngeal phthisis, 
such as distressing cough, and painful deglutition, almost en- 
tirely abseftt. 

Treatment. — Iodide of potassium is of little avail in the man- 



310 SYPHILIS OF THE LARYNX. 

agement of tliis affection. The patient should be put immedi- 
ately under the use of mercurials administered internally, and 
by baths or inunctions, under the rules which govern the treat- 
ment of any case of s^q^hilis. In addition to this, local meas- 
ures should be used for the arrest and removal of the ulcerative 
process. These should consist, first, of a thorough cleansing of 
the surface of the ulcer, by the use of one of the cleansing so- 
lutions given in the Appendix. These should be applied by 
means of the atomizer, in the absence of which, however, there 
is no objection to the use of the cotton pellet or sponge, as the 
larjnix is not especiall}^ irritable in this disease, and the intro- 
duction of sponge or probe is not objectionable to the same 
extent as it is in laryngeal phthisis, where the parts are exqui- 
sitely sensitive, and where harm may be done by such rude pro- 
cedure. After cleansing the surface of the ulcer it should be 
coated with one of the following ^^owders : 

I^ . Iodoform, 

Lycopodii afi 3 j. 

M. 

I^ . Morphia sulpli gi'- i.l- 

Iodoform 3 j. 

M. 

I^ . Iodoform = 3 ij. 

Tannin 3 j. 

M. 

These may be applied by means of the powder blower 
shown in Fig. 47. This instrument, of course, does not 
nicely localize the medication on the diseased surface, but that 
portion which is diffused over the surrounding membrane is 
soon voided, while that portion which covers the ulcer remains 
adherent to it. The cauterization of the ulcer with nitrate of 
silver, or other agents, is often recommended. Caustic appli- 
cations add to the destruction of tissue, are extremely painful, 
and in my experience are not so satisfactory in their results as 
the use of the iodoform in one of the combinations given above. 
These powders are entirely painless, are quite inert on the mu- 
cous membrane surrounding the ulcer, and are speedy in their 
action on the diseased surface. 



deep ulcees of the lakyjstx in syphilis. 311 

Deep Ulcers of the Laeynx ix Syphilis. 

This form of laryngeal sypliilis consists in the development 
in the mucous membrane of the larynx of an ulcerative process, 
characterized by the rapidity of its destructive progress, and 
the depth and extent to which the tissues are involved in its 
action. It is essentially a tertiary lesion, making its appear- 
ance, as a rule, from five to fifteen years after the primary le- 
sion, though occasionally it is met with as early as the fourth 
or even third year of the disease. 

It is probable that most, if not all cases of deep ulceration 
in syphilis, are due to gummy tumors, for, as we know, these tu- 
mors, wherever deposited in the mucous membrane, manifest a 
tendency toward rapid disintegration and the formation of ul- 
cers, which develop so speedily that it is a comparatively rare 
occurrence to meet with the gummy tumor before the ulcerative 
process has set in. This tendency to suppuration in these tu- 
mors would naturally be much greater in the larynx than in any 
other portion of the upper air-passages, hence the opportunit}^ 
of observing a gummatous deposit in this cavity would prob- 
ably be an exceedingly rare event. We may say, then, with 
a considerable degree of positiveness, that these ulcerations are 
due to the disintegration of gummy tumors. Their usual site 
is either in the false cords, epiglottis, or ary-epiglottic folds ; 
but, wherever their starting-point may be, their extension is 
comparatively rapid, and they soon involve the neighboring 
parts. One peculiarity, however, is noticeable in these ulcers, 
viz., their tendency to confine themselves to one side of the 
larynx. This is especially true where their origin is in the 
false cords ; but when involving the arytenoid cartilage or 
epiglottis, they seem to manifest a hesitancy in extending to 
the opposite side, though still manifesting their destructive 
character on the side of the larynx in which they originated. 
They also show little disposition to extend into neigliboring 
organs, ^s for instance, tliey rarely, if ever, extend to the 
])luuynx or oesophagus, when their origin has been in the 
larynx. They do, however, occasionally extend beyond the 
epiglottis to the root of the tongue. Having their origin in the 
larynx itself, they may go on to the complete destruction of 
the epiglottis, ary-epiglottic folds, the arytenoids, and, in 



312 SYPHILIS OF THE LAEYNX. 

deed, the whole organ. In Fig. 121 there is shown the rav- 
ages of this form of syphilis, as going on to the almost com- 
plete destruction of the epiglottis, yet still confining itself to 
the left ventricular band, without attacking the right side of 
the laryngeal cavity. 

As a matter of clinical observation, we meet with this mani- 
festation of sj^philis in the larynx a number of years after the 
primary lesion, in cases where there have been none of the 
intermediate stages of the disease. In 
"^ - ' r:;;^ S "^^^ my experience, in quite a number of 

^ \jf^ ^^ cases, the disease, after the primary 
' r W m IK^ inoculation, seems to have remained 
^^Wm latent through all these years until 
\^:s^^^^^ there crops out. or manifests itself 
in the larynx, these deep ulcerations 



\\G 121 —The leep nkcrat 

philis m\ol\in<; the episil )ttis £ 

left vtntiiculai bind (Micktiizic ) 



phiii« iinohin- the epmi .ttis and the uuder cousideratiou. Why the clini- 



cal history of these cases should be 
so imperfect, and there should be this absence of the second- 
ary stages which, ordinarily, mark the progress and develop- 
ment of the disease, it is difficult to explain ; it is merely an 
observed clinical fact. That there should have been any error 
of diagnosis, is excluded by the fact that the cases yield kindly 
and oftentimes brilliantly to the administration of anti-syphi- 
litic treatment. After the ulcerative process has been estab- 
lished, its progress, as has been before stated, is rapid and de- 
structive, involving the mucous membrane and extending to 
the perichondrium and cartilages which, in turn, disappear 
under its ravages. A further prominent characteristic of this 
disease is the great deformity which results from the cicatri- 
cial contractions after the liealing of the ulcers. This is more 
marked after this form of ulceration than any other. This, 
perhajjs, may be accounted for by the very great extent of the 
destruction of tissue, and consequently by the large void which 
must be closed ; and which is filled in the main by the drawing 
together of the cicatricial tissues, and in part only by granula- 
tions. These cicatricial deformities assume shape according to 
the location and extent of the ulceration. The symmetry of 
the larynx, wdiich has been already marred by the original ul- 
ceration, is still further disturbed by the resultant cicatrix, so 
that we may have the epiglottis drawn to one side, or down 
toward the arytenoid cartilages, or the cavity of the organ en- 



DEEP ULCERS OF THE LARYNX IN SYPHILIS. 313 

croaclied upon by bands of cicatricial tissue ; in fact, the extent 
of the deformity to which the larynx may be subjected by 
these cicatrices is only limited by the extent to which the ul- 
cerative action may destroy. A complete stenosis as the result 
of these cicatricial contractions is not an infrequent occurrence, 
to which the only relief that can be given lies in the perform- 
ance of tracheotomy. 

Sym%)toins. — The onset of this form of syphilis in the larynx 
is usually sudden and unexpected. The patient in the enjoy- 
ment of perfect health, as a rule, suddenly experiences a sense 
of pain and discomfort referable to the larynx, followed by a 
more or less hacking cough and impairment of voice — a mere 
huskiness or slight hoarseness. The pain soon becomes more 
aggravated, and is a constant source of distress. Difficulty of 
swallowing, slight at first, soon becomes more marked, and the 
pain attendant upon the act, of an acute lancinating character. 
If tlie disease is located on or involves the arytenoid cartilages 
or commissure the voice is completely lost, while the pain in 
swallowing is quite marked, owing to the pressure on the 
ulcerated surface during the act. If the epiglottis is involved 
painful deglutition becomes still more prominently a distress- 
ing symptom. 

In general, it may be stated that impairment of voice and 
difficulty in swallowing are the two prominent and character- 
istic symptoms of the afilection, the extent to which they are 
present being dependent on the locality of the ulceration. As 
the disease progresses these symptoms become somewhat ag- 
gravated, and a cough, which at first was but a slight source of 
discomfort, becomes of a constant and irritating character, due 
in part to a sensation on the part of the sufferer of a foreign 
body in the larynx, which it is his constant effort to avoid by 
hawking and clearing the fauces, and in part, to the profuse 
discharge of mucus and pus which soon sets in. As the de- 
struction of the tissue progresses, the difficulty of swallowing 
becomes still more aggravated by the particles of food lodging 
upon the ulcer or making their way into the air-passages. 
The protection afforded by the epiglottis and ary-epiglottic 
folds is, to an extent, lost, their function of affording covering 
to the larynx being impaired by loss of tissue, by the deform- 
ity which results from the ulceration, and also by the impair- 
ment of motion. 



314 



SYPHILIS OF THE LAKYXX. 



Diagnosis. — There is no disease of an ulcerative character 
which presents appearances which can easily be mistaken for 
the one under consideration, and the diagnosis is comparatively 
simple, provided that a satisfactory laryngoscopic examination 
is obtained. Genuine ulcers, once recognized, may be assigned 
to one of the general dyscrasia before alluded to as alone giv- 
ing rise to ulcerations of the mucous membranes. In the la- 
rynx we meet with superficial ulcers of syphilis, deep-seated 
ulcers of syphilis, laryngeal phthisis, and epithelioma, each of 
which present certain characteristic appearances which belong 
to each individually, and which distinguish the one from the 
other so decidedly that the diagnosis is made comparatively 
simple. These will be better appreciated, perhaps, by group- 
ing them in a tabulated form. 



Superflcifd Ulcers of 








Syphilis. 


Deep Ulcers of Syphilis. 


Laryngeal Phthisis. 


Carcinoma. 


Faintly marked areola. 


Deep, angry, red, and 


No areola. 


No areola, but enlarged 




swollen areola. 




blood-vessels leading up 
to ulcerated surface. 


Eopy mucus, or muco- 


Purulent discharge mLxed 


Glairy mucus or muco- 


Muco-puralent discharge. 


purulent discharge. 


with necrotic tissue 
and debris. 


purulent discharge. 




Scanty discharge. 


Very copious discharge. 


Scanty discharge. 


Moderately profuse dis- 
charge. 


Grayish-colored surface. 


Bright yellow sm-face. 


Grayish surface, often 


Grayish surface dotted 






like cut bacon. 


with pinkish elevations, 
often. 


Of an oval and somewhat 


Rageed and irregular 


Faintly marked outline, 


Somewhat jagged outline 


regular outline. 


outline. 


but somewhat regular. 


and everted edge. 


Surface not depressed. 


Deeply excavated. 


Depression of surface not 


Surface often raised 






marked. 


above surrounding tis- 
sues. 



Examination. — Tlie appearance of the deep ulcer is char- 
acteristic and unmistakable. Its surface is coated with bright 
yellow pus, mingled with necrosed fibres, and debris result- 
ing from the ulcerative process. Its borders are somewhat 
jagged, slightly irregular, and overhang the surface of the 
ulcer, which is depressed and excavated. The mucous mem- 
brane surrounding the ulcer is in a state of active and acute 
inflammation, forming an areola of deepl}^ injected, bright, 
angry-looking membrane, having all the appearances of a 
phlegmonous intlammation, but of a somewhat deeper color, 
verging on a coppery hue. It is swollen and distended, having 



DEEP ULCEES OF THE LAEYNX IN SYPHILIS. 315 

sometliing of a glazed appearance, and is covered with a tliin, 
slimy mucus or muco-pus. This coating is oftentimes of a 
frothy character, and clings closely to the part ; this is owing 
to the fact that the vibratory movement of the cilise of the 
epithelium covering the membrane is destroyed by the inflam- 
matory process, and the ability of the sufferer to void or ex- 
pectorate it is thereby impaired. This coating, therefore, 
oftentimes covers and conceals to an extent the morbid process, 
which can only be recognized after cleansing the parts by 
means of the spray or other devices. 

Treatment. — No form of ulceration in the larynx sets in so 
suddenly, spreads so rapidly, or involves such extensive de- 
struction of tissue in so comparatively brief a period of time, 
as the deep ulceration of syphilis, hence its early recognition 
and prompt treatment become of the utmost importance. In- 
ternal medication alone, it is often asserted, is quite sufficient 
for the arrest of the disease at its onset. This may be true, 
and yet, where the early accomplishment of this result is of so 
great moment to the sufferer, it becomes a question whether the 
greater safety does not lie in the combination of internal and 
local treatment. During the time consumed in bringing the 
patient thoroughly under the influence of internal remedies, 
the destruction of tissue is still going on, and this not infre- 
quently may be days, or even weeks ; and even in this time 
the disease may have so fixed itself upon the part as to become 
if not entirely incurable, certainly more intractable. Laryngeal 
syphilis is a disease which may very easily escape beyond our 
control, hence the importance of its early recognition and early 
treatment cannot be overestimated. Furthermore, it needs to 
be combated by every means within our power. In local medi- 
(•ation we possess a means, both speedy and efficient, of arrest- 
ing the further progress of these ulcers, and it should always 
be employed in connection with internal medication. The con- 
stitutional remedy which above all others is efficient, and to 
which preference should always be given in these deep ulcera- 
tions in the larynx, is iodide of potassium, given in full and 
increasing doses until a decided impression has been made. 
Commencing with twenty grains, given three times daily, the 
dose should be increased five grains every third day until marked 
improvement is noticed in the diseased organ, or the farther 
administration of the drug is interfered with by the production 



316 SYPHILIS OF THE LAEYNX. 

of iodism, as sliowu by the eruption on tlie skin, or the occur- 
rence of coryza or catarrh of the upper air-passages, when the 
dose, of course, must necessarily be reduced. The administra- 
tion of mercury alone in this manifestation of syphilis is use- 
less, and it is a waste of time to give it. After the laryngeal 
disease, however, has been arrested, mercury should be given 
for a period of from twelve to eighteen months, under the rules 
which govern its administration for the cure of the constitu- 
tional taint. 

Local treatment. — The parts should be thoroughly cleansed 
b}^ the use of the laryngeal sj^ray, directed as closely as possi- 
ble against the ulcer until all the accumulated pus and necrosed 
tissue are thoroughly removed from the diseased surfaces. The 
fluid used may be one of the cl'eansing solutions given in the 
Appendix. The spray is best applied with the compressed air 
apparatus, with a pressure of about twenty pounds. 

The efficiency with which the cleansing is done should 
always be tested by an examination. If an overhanging epi- 
glottis or any other obstacle prevents the use of the spray, the 
laryngeal probe may be used with a pellet of cotton, or a sponge 
may be introduced with the sponge-holder, and the cavity of 
the ulcer wiped out and cleansed, the slight stimulation re- 
sulting from this procedure being in no way objectionable. 
Occasionally it will be found necessary, on account of the 
amount of the accumulated debris, to make use of the laryn- 
geal syringe shown in Fig. 56. Its beak may be passed over 
the epiglottis and the cleansing fluid thrown directly into the 
laryngeal cavity with impunity, the natural contraction of the 
parts preventing its making its way into the trachea. After 
the parts are thoroughly cleansed and seen to be so, by inspec- 
tion with the laryngeal mirror, there should be thrown in by 
the atomizer a mild astringent to control and correct the 
catarrhal inflammation of the mucous membrane surrounding 
the ulcer. For this purpose there may be used tannic acid or 
sulphate of zinc ten grains to the ounce, chloride of zinc five 
grains to the ounce, nitrate of silver two grains to the ounce, 
or, in fact, any simple, unirritating astringent. 

After this there should be used iodoform for its specific 
action on ulceration. This should be combined with morphia, 
of the strength of two grains of morphia in one drachm of iodo- 
form. It should be thrown directly upon the ulcerated surface 



DEEP ULCEES OF THE LARYNX IN SYPHILIS. 317 

in sncli a way that it will penetrate as thoroughly as possible, 
the excavation. This may be accomplished by the powder 
blower shown in Fig. 47, or perhaps better still, Stoerck's in- 
strument shown in Fig. 48, which can be manipulated with the 
aid of the mirror, and the deposit localized with more nicety. 
The success of the application should be noted by examination 
with the laryngeal mirror, and it should be repeated until such 
an examination shows that it has been thoroughly done. The 
use of caustics or any destructive agents in the treatment of 
these deep ulcerations is rarely if ever indicated, as in the 
measures above described we have a safe, thoroughly efficient, 
speedy, and painless method of treatment, which leaves little 
to be desired. The application of caustics is painful, it adds 
to the destruction of tissue, produces spasm of the glottis, 
oftentimes of an alarming character, it is difficult of manipula- 
tion, and is rarely confined to the ulcerated surface. It also 
requires a special skill which, while it should be in the posses- 
sion of every physician, unfortunately is not. The manipula- 
tion necessary to carry out the plan outlined above, on the 
other hand is possessed by every physician who has mastered 
the simplest details of laryngoscopy. 

In closing the subject of laryngeal syphilis it should be 
stated that while the classification of the specific manifestations 
given, is the one which my own observation of a considerable 
number of these cases has led me to adopt, it is not intended 
to convey the idea that these conditions all manifest themselves 
independently, for they do not. We meet not infrequently 
with cases in which one condition is implanted upon another. 
The most frequent of these is the occurrence of the superficial 
ulcer, in connection with the chronic laryngitis of syphilis ; 
less frequently the deep ulceration may be met with in con- 
nection with this manifestation. 



CHAPTER XIX. 

STENOSIS OF THE LAEYNX. 

In its broader signification, by a stenosis of tlie larynx may 
be meant, any morbid condition which encroaches upon tlie 
lumen of the cavity, and serves thereby to produce interfer- 
ence with normal respiration. More strictly, however, the term 
should be confined to that condition in which the narrowing is 
due to an infiltration of the mucous membrane proper, or the 
submucous tissues, producing d^^spncea ; or to the result of 
cicatricial contractions. By far the most frequent cause of 
this condition is syphilis. This disease may cause stenosis, 
either as the result of the cicatricial contractions which follow 
the deep tertiary ulceration, or the stenosis may arise as a 
sequela of that form of syphilis described as the chronic catar- 
rhal laryngitis of syphilis ; the morbific products of the disease 
being deposited in the deep layers of the membrane, and en- 
croaching on the laryngeal cavity, both by the extent of infil- 
tration, and also by the contraction which is liable to ensue 
as the disease progresses. Other conditions which may cause 
laryngeal stenosis, are idiopathic or specific perichondritis, or 
chondritis ; or it may be the direct result of injury. That nar- 
rowing of the upper air-passages, which may be the result of 
pressure by aneurism, carcinoma, fibroid tumors, enlarged 
glands, etc., does not properly belong to genuine stenosis of 
the larynx. 

The symptoms resulting from this condition, aside from 
those due to the disease which causes it, are all embraced 
under the one symptom of dyspnoea. From a moderate short- 
ness of breath, not particularly noticeable, there gradually de- 
velops, by a progress oftentimes so slow as to consume months 
in making itself prominent, a dyspnoea which sooner or later 
will demand tracheotomy unless relief can be afforded by other 
means. 



STElsrOSIS OF THE LAEYNX. 319 

As an almost invariable rule, no measures of internal medi- 
cation are of any avail in arresting the progress of tlie stenosis, 
after the morbid process which causes it has once set in. Es- 
pecially is this true if the disease be due to cicatrization fol- 
lowing the deep ulcers of syphilis, or to the non-ulcerative ter- 
tiary form of the constitutional taint. As the disease progresses, 
therefore, and the dyspnoea becomes marked, it will become 
absolutely necessary to open the trachea. The difficulties in 
the way of the treatment of the condition are very greatly in- 
creased, unless tracheotomy has been previously performed, 
hence the operation, even if not demanded by the urgency of the 
symptoms, is justified on this ground alone. Furthermore, the 
total rest and quiet afforded to the larynx by opening the 
trachea, will very materially aid the success of measures re- 
sorted to for remedying the stenosis. 

Treatment. — The treatment of laryngeal stenosis is not un- 
like that of urethral stricture, being only modified by the differ- 
ing anatomical and physiological characteristics of the organ. 
Among the measures resorted to for its relief we have gradual 
dilatation, forcible dilatation, and the cutiing dilator. Corre- 
sponding to the ordinary urethral sound, the forcible dilator 
and the urethrotome. 

Occasionally attempts have been made to dilate a stenosed 
larynx before tracheotomy has been performed, making use of 
hollow tubes or bougies ; as a rule, however, the treatment is 
carried out after the introduction of a canula. 

Schroetter, of Vienna, has reported a number of successful 
cases in which the stenosis was permanently overcome by 
gradual dilatation, by means of a series of metallic bougies, of 
a somewhat triangular shape, about one and a half inch in 
length, and varying in diameter from one-fourth of an inch to 
two-thirds of an inch, there being twenty-four sizes. Each bou- 
gie has a small opening through it from end to end. Into this 
opening fits a slender rod, slightly longer than the bougie. The 
upper end of the rod has an ej^e into which is fastened a cord, 
while the lower end is expanded into a small knob. The pa tient 
having undergone such training, by the daily introduction of a 
probe into the larynx, as will enable him to tolerate the x')as- 
sage of the bougie, the plan of procedure is as follows : The 
bougie is passed into the larynx by means of a bent canula, 
mounted in a handle, as shown in Fig. 122. The cord attached 



320 



DISEASES OF THE LARTNX. 



to the bougie is drawn tlirongli the canula and fastened at the 
extremity of the handle. The bougie having been passed into 
tlie larynx, the knob on the lower end of the rod passing 
through its centre, emerges in the tracheal canula, through a 
fenestrum in its upper surface, where it is seized and held, by 
a small pair of spring forceps inserted through the cervical 
end of the canula. The bent canula is now withdrawn, leaving 
the cord protruding from the mouth. The cord can now be se- 




Pm. 122.— Schroetter's laryngeal dilator in situ. (Labus.) From Cohen. 

cured by tying around the neck, and the bougie left in place for 
a length of time, varying with the tolerance of the patient. At 
the commencement of treatment this will be perhaps not lon- 
ger than a half hour, but as the parts become tolerant it may 
be left in place a day, or longer, and need only be removed for 
purposes of cleansing. When it is desired to remove the bou- 
gie, the spring forceps are unclasped, when it can easily be 
drawn out by means of the cord. 

Schroetter has modified this instrument, somewhat, by sub- 



STENOSIS OF THE LAEYNX. 



321 



stituting for the spring forceps by wliicli the bougie is held in 
place, the inner canula of the trachea tube, as shown in Fig, 
123. 




Fig. 123.— Schroetter'B modified laryngeal dilator. (Mackenzie.) A, the handle with bougie attached, 
ready for passing into the larynx : B, a slender rod for drawing the cord through the handle. The 
bougie X having been passed through the fenestruni in the tracheal canula, is held in place by the inner 
canula C, which passes through a canal in the lower extremity of the bougie. 

The process detailed above is necessarily a very slow one. 
In order to hasten somewhat the progress of the cure a num- 




FiG. 124.— Mackenzie's laryngeal dilator: A, the instrument clo.scd 
r.ent open. 



B, the iiistru- 



ber of instruments have been devised for the forcible dilatation 
of the stenosis. Tliese are intended, mainly, for use in coniiec- 



322 



DISEASES OF THE LARYNX. 



tioii with the bougies, as after the use of the dilator the bougie 
is necessarily introduced in order to prevent the contraction 
which would ensue, unless this were done. 

In Fig. 124 is shown Mackenzie's dilator which consists of 
three blades, bent at the proper angle for introduction into the 
larynx, and operated by means of a screw at the proximal 
end. The instrument is introduced into the larynx, while 
closed, when the blades are opened by turning the screw. The 
amount of distention accomplished is shown by an index and 
dial plate on the handle. 

A somewhat ingenious device on the same plan is shown in 
Fig. 125. This is the dilator of Navratil. It consists of a Ions: 




Fig. 125. — Navratil's laryngeal dilator. (Mackenzie.) 



metallic tube bent at a laryngeal curve and containing within it 
a steel rod. On the distal end of the instrument is mounted an 
olive-shaped bougie (cZ), composed of four segments. These seg- 
ments are attached by movable arms, in part to the outer tube 
and in part to the central steel rod. Sc is a screw at the proxi- 
mal end, and at 7i is a handle by which the patient holds the 
instrument. By turning the screw the central steel rod is drawn 
within the outer tube, bringing forward the movable arms, and 
expanding the segments as shown in d. At m is a scale which 
indicates the extent of the dilatation. 

In Fig. 126 there is illustrated still another device for over- 
coming a laryngeal stenosis, which consists of the combination 
of a dilator with a cutting instrument. Of course it is by no 
means a difficult manipulation to incise a laryngeal contraction 



STENOSIS OF THE LARYJSTX. 



323 




by means of any of the ordinary laryngeal knives. The ad- 
vantage of the instrument shown is in putting the tissues on 
the stretch before they are incised, which renders the cutting- 
more thorough. This instrument is the design of Dr. Whistler, 
of London, and consists of an olive-shaped bougie, containing 
a concealed knife which is only protruded when desired. The 
instrument is so ar- 
ranged that the knife 
may be made to pro- 
trude anteriorly or 
posteriorly. 

The treatment of 
laryngeal stenosis by 
means of any of the 
above-mentioned 
plans is necessarily 
tedious and protract- 
ed, involving, as a Fig. ISe.—Whistler's cutting laryngeal ailator: a, bougie with 
vnlo Q nrvnT'cci ti~vrl-onrl knife concealed ; B, blade protruding; C, knife detached; D, spring 
I Ult^, d, OU Ul fee t;A.LeilU.- ^^ ^^^^^ ^^ ^^^^^^ ^^^ ^^^^^ ^^ ^^^^^ ^^ project. 

ing over from twelve 

to eighteen months. Yet, when we consider the alternatives 
presented to the sufferer, of submitting on the one hand to this 
tedious process, and on the other hand the terrible prospect of 
wearing a tracheal tube during life, it would seem that there 
should be no question as to the advisability of the treatment, 
provided that it offers any certainty as to the ultimate cure. 
Unfortunately, this cannot be assured. Schroetter has re- 
ported and exhibited a number of cases in which the gradual 
dilatation by his bougies has resulted apparently in a perfect 
and permanent cure. On the other hand it should be stated 
that others have not usually obtained the same uniform suc- 
cess in their efforts. 

Of the various devices described, I should give the prefer- 
ence decidedly to the bougies of Schroetter. I see no reason to 
reject the analogy between a urethral and a laryngeal stricture 
already alluded to. The pathological condition is certainly 
very similar in the two diseases, however marked the difference 
in function may be. In urethral stricture, after fair trial of the 
lapid dilatation by rupture and also by cutting, the weight of 
opinion seems to be reverting to the old plan oL' gradual dilata- 
tion. It is a fair inference that the same method will prove 



324 DISEASES OF THE LARYNX. 

more permanently beneficial in the larynx. In those cases in 
which there may exist fibrous bands or webs, it will, of course, 
be well to use Whistler's cutting dilator, although in many 
cases the simple knife or galvano-cautery knife may be used. 

Another plan, that may be very briefly mentioned, for over- 
coming a laryngeal stenosis, consists in the performance of 
thyrotoni}^, by which the laryngeal cavity is opened from 
without, and the offending tissue dissected out. This operation 
necessarily involves the destruction of the special organ neces- 
sary for the production of the voice, but these are destroyed 
already by the disease which has caused the stenosis. 



CHAPTEE XX. 

NEUEOSES OF THE LARYNX. 

General Cois^siDERATioisrs. — The larynx receives its innerva- 
tion from the superior laryngeal and inferior laryngeal branches 
of the pneumogastric nerve (see Fig. 127). The motor fibres, 



Communicating branch- 



PoRtcrior crico-nrytenoid ) 
muscle, the belly being > 
removed. ) 

JJranch to the poRterior I 
cricd-arytenoid muscle, ) 




Superior laryngeal nerve. 



Arytenoid muscle, the 
lower half removed. 



( Posterior crico - aryte- 
"/ noid muscle. 
J Branch to the posterior 
"( crico-orytcnoid muscle. 



J Inferior or recurrent 
"I laryngeal nerve. 



Pig. 12T.— The kiryugcal 



(Luschka.) 



however, have their origin in the spinal accessor}^ nerve, while 
sensation alone is suiiplied by the pnenniogastric. 

Tlie superior larynr/ml nerve ^vma^ from the inferior gan- 
glion of the pneumogastric, and passes, down behind the in- 



326 



NEUROSES OF THE LARYNX. 



ternal carotid arteiy to tlie side of the pharynx, where it 
divides into two branches ; the external branch passing down 
to supply the crico-thyroid muscle, while the internal branch 
pierces the thyro-hyoid membrane, and is distributed to the 
mucous membrane of the larynx and to the arytenoid muscle. 
It is in the main a nerve of sensation. 

The inferior or recurrent laryngeal nerve is in the main a 
nerve of motion. Its course varies on the two sides of the 




• Mastoid process. 

■ Jugular vein, cut off. 
Gangl.on of the trunk. 

Internal branch of the spinal accessory. 
Pharyngeal branch of the pneumogastric. 
Superior laryngeal nerve. 

Internal branch of the superior laryngeal nerve. 
External branch of the superior laryngeal nerve. 

■ Left pneumogastric nerve. 
■Thyro-hyoid muscle. 

. Cardiac branch of the left pneumogastric. 
. Right pneumogastric nerve. 
Cardiac branch of the right pneumogastric. 



■f| Eight recun-ent laryngeal nerve. 

--Left recurrent laryngeal nerve. 



Ductus arteriosus. 



Fio. 128.— The laryngeal branches of the pneumogastric nerve in the newly born child. (Henle. ) 

body in a manner which becomes of importance in a patliolo- 
gical point of view, owing to the fact that, while on the right 
side it arises in front of the subclavian artery, on the left 
side it arises in front of the arch of the aorta. After passing 
from above downward and backward around these vessels, 
the nerves on both sides generally pass to the side of the 
trachea and ascending in the sulcus between the oesophagus 
and trachea, enter the larynx behind the articulation of the 



NERVE DISTEIBUTION IN THE LARYNX. 



327 



inferior cornna of the thyroid cartilage with the cricoid. They 
suppl}^ motor filaments to all the muscles of the larynx except 
the crico-thyroid. A reference to Fig. 128 will show this vari- 
ation in the coarse of the nerves of the two sides, while in Fig. 
129 a transverse section of the neck is given, which indicates 
more clearly the position of the left recurrent nerve, bending 
forward in a somewhat more exposed position than its fellow 
of the opposite side. The recurrent nerve also sends off a num- 



Tracheal carti 
lage. 



Thyroid gland 



Left recurrent 
laryng'l nerve 




Thyroid gland. 



( Kight recurrent 
/ laryng'l nerve. 
(Esophagus. 



Body of the i 
vertebra. | 



Fig. l-i9.— ' 
(After Braune. 



( Apex of right 



through the neck at the lower surface of the first dorsal vertcbrfe. 




ber of small branches, which are distributed to the oosophagus, 
trachea, and pharynx. 

In general, in regard to the two nerves, it may be stated 
that the superior laryngeal nerve supi^lies sensation to the 
mucous membrane lining the larynx down to the level of the 
vocal cords, with motor filaments to the crico-thyroid muscle, 
and possibly motor filaments to the arytenoideus and thyro- 
epiglottidean muscles. This, however, is still an unsettled 
question, and being so, we may adopt the view that the crico- 
thyroid muscle is the only one which receives its innervation 
from the superior laryngeal nerve. 

The recurrent laryngeal nerve sui:)plies motor filaments to 
all the muscles of the laiynx, except the crico-thyroid, and 
also supplies sensation to tlie mucous UKMnbrane of the trachea 
as far up as the edge of the vocal cords. 



328 NEUROSES OF THE LARYNX. 

It has been usual to make a classification of neuroses of the 
larynx, based mainly on the above anatomical considerations. 
Whether this be the true method of classification is certainly 
open to question, as it would lead to the description of dis- 
eases which we probably never meet with clinically. 

Anaesthesia, hypersesthesia, paraesthesia, and neuralgia of 
the larynx undoubtedly may exist to a more or less well- 
marked extent, but "whether they occur as separate and dis- 
tinct alTections, and are entitled to consideration as such, is 
certainly an open question. In approaching death, for in- 
stance, anesthesia of the larynx occurs, but it is simply in 
connection with the failure of all the powers. Hypera^sthesia 
of the larynx occurs in laryngeal phthisis, but it is merely a 
symptom of that disease ; the same may be said in regard to 
the engorgement which accompanies the existence of tumors 
or ulcerations. That paralysis, due to any morbid condition 
of the superior larjnigeal nerve, such as neuritis, pressure of 
tumors, diphtheria, etc., will produce loss of sensation in the 
parts to which the nerve is distributed is undoubtedly true ; 
but so long as this disease is described as one which might 
possibly occur rather than one wliicli has been clinically ob- 
served, it w^ould seem that its introduction into a treatise on 
these affections would be something of a refinement in classi- 
fication. The genuine neuroses which we meet with in the 
larynx are those due to defective innervation through the re- 
current laryngeal nerve ; in this connection, however, reference 
will be made to paralysis of the individual muscles. 

These subjects will be discussed under the following heads : 

Unilateral recurrent laryngeal paralysis. 
Bilateral recurrent laryngeal paralysis. 

Unilateral paralysis of the crico-arytenoideus posticus muscle. 
Bilateral paralj^'sis of the crico-arytenoideus posticus muscles. 
Unilateral paralysis of the crico-arytenoideus lateralis muscle. 
Bilateral paralysis of the crico-arytenoidei laterales muscles. 
Unilateral paralysis of the thyro-arytenoideus muscle. 
Bilateral paralysis of the thyro-arytenoidei muscles. 
Paralysis of the arytenoideus milscle. 



EECURRENT LARTNaEAL PARALYSIS. 329 



Recurrent Laryngeal Paralysis. 

This is a paralysis of all the parts supplied by this nerve 
due to some morbid condition of the nerve-centre or the nerve- 
trunk. In the majority of cases this consists in pressure upon 
the nerve, though occasionally a diseased condition of the 
nerve- trunk or nerve-centre nia}^ be the source of the paraly- 
sis. Among the conditions which may produce this disease, 
are apoplexy, softening of the brain, etc., but, as a rule, the 
source of the trouble is in some injury to the nerve-trunk itself. 
On the right side it will be remembered that the nerve passes 
around the subclavian artery, while on the left side it passes 
around the arch of the aorta, and in its course to the larynx 
lies somewhat nearer to the surface. It is therefore more ex- 
posed to injury and to pressure. As a matter of clinical fact, 
paralysis of the left recurrent nerve is of far more freqaent 
occurrence than paralysis of the right ; indeed, I have never 
met with but one case of paralysis of the right recurrent nerve, 
while I have recorded some twenty-five cases of left recurrent 
paralysis. Among the conditions which produce the disease 
are enumerated, aneurism, carcinoma, bronchocele, enlarged 
bronchial gfands, rheumatic affections, the various forms of 
tumors which may occur in the neck, indurations at the apex 
of the right lung, and in fact any condition which may pro- 
duce pressure on the nerve-trunk, and thereby, interruption of 
the nerve-current. Perhaps the most frequent of all causes is 
aneurism of the arch of the aorta. 

Next in frequency, as a cause of the affection, is syphilis, 
without assigning any especial manifestation of the disease as 
producing the paralysis. Of the twentj^-iive cases above men- 
tioned, most of which have presented at the Bellevue Throat 
Clinic in the last eight years, six have been due to discover- 
aljle aneurism, four to probable aneurism, four to enlarged 
brorirhial glands, two to cancer of the cesophngus, six to 
syphilis, and in three there was no discoverable cause ; one of 
these was a young girl of seventeen. In the one case in wliicli 
the affection occurred on the right side, it was due to prcssun' 
on the nerve-trunk by the induration of incipient phthisis of 
the right lung. 

Symptoms. — The symptoms ])ointing to this affection are 



BBO NEUROSES OF THE LARYXX. 

not prominent or distinctive. Occasionally cases are met with 
in which no sjnnptoms whatever are present, more than a slight 
and almost imperceptible impairment of the ordinary voice. 
At other times the voice may be seriously impaired, its regis- 
ter markedly lowered, and talking accomplished with more or 
less effort, the voice being weak and tiring easily. Congh may 
be present, but due usually to a catarrhal laryngitis which de- 
velops, as the result of overtaxing the muscles of phonation, 
weakened by the paralysis. This consists in a straining of the 
muscles of one side to counterbalance the paralj^sis of the 
opposite side. Breathing is rarely, if ever, interfered with, and 
dyspnoea due to the paralysis itself never occurs, although it 
may occur as a symptom of the disease which j^roduces the 
paralysis, such as aneurism, tumors, etc. 

There may be a considerable degree of irritation in the 
laryngeal membrane, due to the venous congestion caused by 
the interference with the return circulation, on account of the 
aneurism or tumor which is the source of the paralysis. This 
irritation may be the source of no little annoyance and even 
distress to the sufferer, the obstructive congestion leading 
soon to a low form of chronic catarrh of the larynx, attended 
with considerable swelling of the parts with the secretion of a 
thick, ropy, tenacious mucus, which is expectoraT;ed with con- 
siderable difficulty. In these cases the voice is apt to be seri- 
ously impaired, assuming a thick, husky character. It is also, 
at times, of a somewhat higher pitch, verging on the falsetto 
tones, especially at the onset of the paralysis. Cough, also, in 
these cases, becomes quite a prominent symptom of the affec- 
tion, due, mainly, to the laryngeal catarrh. 

Examination. — An examination of the larynx will reveal 
the condition unmistakably. In making an observation, how- 
ever, it is of importance that the lar3aigeal mirror should be 
exactly in the median line, and that a perfectly symmetrical 
image should be obtained, as a distorted or unsymmetrical 
image will prove very deceptive, and oftentimes fail to re- 
veal a lack of motility which may exist. A symmetrical 
view having been obtained, it will be seen that one of the 
'Cords lies half way between extreme adduction and abduction 
(see Figs. 130 — 131), that is in the so-called cadaveric posi- 
tion. This, of course, is the position which the cord would 
naturally be supposed to assume when entirely free from any 



RECURRENT LARYNGEAL PARALYSIS. 331 

muscular control, as it is in this form of paralj^sis. This posi- 
tion of rest in the cadaveric position remains during phonation 
and inspiration. But daring phonation it will be seen that the 
arytenoid cartilage does not remain motionless, as a rule, but 
at the commencement of the act it will on close observation be 
noticed that it is tilted or drawn spasmodically, as it were, 
toward its fellow of the opposite side. This is explained by 
the fact that the arytenoideus muscle, being supplied by the 
recurrent nerve of each side, is not paral^^zed with the other 
muscles, but receives sufficient innervation from the unaffected 
nerve to act still on the arytenoid cartilage of the opposite side. 
During the act of phonation it will also be noticed that the 
cords are fairly approximated. This is accomplished by the 
increased action of the adductor muscle of the sound side of 
the lar^^nx, carrying the cord to the median line and beyond it 





Pig. 130. — Rigbt recniTent paralysis ; position of the cords in inspiration. (Maclcenzie.) 
Fig. I'll. — Kight recurrent paralysis ; position of the cords in phonation. (Mackenzie.) 

in such a manner that it is still brought into approximation 
with its fellow of the paralyzed side sufficiently close for pho- 
nation, moving in the larger arc of a circle than normally. 
Another characteristic appearance of recurrent laryngeal par- 
alysis is noticed, namely, that the arytenoid cartilage of the 
mobile side swings in front of the arytenoid of the paralyzed 
side. This condition will be understood by reference to Fig. 
131, which will show the deviation from tlie antero-posterior 
line of the opening between the vocal cords during phonation, 
and also the characteristic position of the arytenoid cartilages. 
In addition to this, it will be noticed that the cord of the 
paralyzed side, during the act of phonation, instead of coming 
up into perfect parallelism with its fellow of the opposite side, 
assumes a bowed condition due to the paralysis of tension of 
the cord, as the result of which it becomes relaxed in this act. 
It yields before the pressure of the column of air, and assumes 
the position above mentioned. 



332 NEUROSES OF THE LARYNX. 

We thus have, as the result of paralysis of the recurrent 
nerve, a paralysis of abduction, adduction, and tension of one 
side of the larynx, which in combination produce the condi- 
tion above described. 

Diagnosis. — The only condition with which the affection 
under consideration may be confused is that of unilateral pa- 
ralysis of the crico-arytenoideus posticus muscle, or of abduc- 
tion. In this latter affection, however, the paralyzed cord lies 
exactly in the median line, in contradistinction with the cada- 
veric position of the cord in recurrent lar3'ngeal paralysis. 
There is no paralysis of tension, and the arytenoid cartilages 
remain perfectly in line during phonation. A close inspection 
should always enable the observer to recognize the characteris- 
tic difference between these two conditions. 

AVith paralysis of the abductor of the cord, the crico-ary- 
tenoideus lateralis muscle, the affection under consideration 
might be confounded, but in this form of paralysis the vocal 
cord lies in a state of extreme abduction, in contradistinction 
with the cadaveric position of the cord in recurrent laryngeal 
paralysis. In addition to this it will be noticed, on inspection, 
that in the attempt at phonation the cords are not approxi- 
mated, but that the mobile cord is drawn only to the median 
line or possibly somewhat beyond it, but is not drawn far 
enough to meet its fellow of the opposite side. The symptoms 
of the two affections, also, are different, in that the voice is lost 
in paralysis of adduction, while in recurrent laryngeal paraly- 
sis it is but moderately impaired. 



Double Rpxurrent Laryngeal PARALY^SIS. 

This is an extremely rare affection, but is occasionally 
met with as the result of the same causes, which may pro- 
duce it on one side, acting on the recurrent laryngeal nerves 
of both sides. The cases reported of this affection have been 
due to cancer of the oesophagus and aneurism of the arch of 
the aorta, extending sufficiently to produce pressure on both 
nerve-trunks. The result of paralysis of both nerves is of 
course complete paralysis of all the muscles of the larynx with 
the exception of the crico- thyroid, whereby the functions of 
tension, abduction, and adduction of the cords are entirely de- 



PAEALYSIS OF Il^DIVIDUAL MUSCLES. 



333 




stroyed and the larynx assumes the position before spoken of 
as the cadaveric position (see Fig. 132). The symptoms which 
characterize this aifection are, in tlie main, complete loss of voice, 
with inability to cough. The loss of voice is explained, of course, 
by the immobility of the cords 
and their failure to approximate. 
The inability to cough is due to 
the ablation of a very important 
element in the mechanism of 
coughing, namely, the spasmodic 
closure of the cords, which pre- 
cede&> the rush of expired air 
which carries with it the secre- 
tions which it is the effort of the 
cough to remove. There is also 
present what has been termed a 
phonative dyspnoea, namely, a 
loss of breath resulting from the 
abortive effort at jDhonation. The 
diagnosis is, of course, quite sim- 
ple, and there is no other con- 
dition with which it can be easily 
confounded. The only affection 
which it resembles is bilateral pa- 
ralysis of the adductors, namely, the crico-arytenoidei laterales 
muscles. In this latter affection,- which is an extremely rare 
one, the cords lie in a state of extreme abduction, which on an 
ordinary careful examination should not be mistaken for the 
midway position Avhich the cords assume in the disease under 
consideration. 




Fig. 132. — The cadaveiic position of the 
vocal cords drawn from a laiynx remo\ed 
from a recent cadavei the position the coids 
would assume in double recurrent laryngeal 
paralysis. (From Ziemssen.) 



Paralysis of Individual Muscles, 



While not necessarily neuroses in the strict sense of the 
term, it is generally the practice to consider paralyses of the 
individual muscles of the larynx under the same heading as 
those of neuropathic origin. The affections already treated of 
are true neurotic affections of the larynx, while in paralysis of 
the individual muscles we must look for the source of the dis- 
ease in the muscles themselves. Without entering into a lengthy 



334 NEUROSES OF THE LARYNX. 

discussion of the true pathology of these cases, it is sufficient 
to say that while the investigations heretofore made, throw- 
comparatively little light upon it, the burden of the testimony 
seems to point to the conclusion that the seat of the disease lies 
in the muscle itself, in some nutritive or degenerative changes 
by which its contractility is destroyed and consequently its 
function abolished. The usual changes reported in those cases 
which have been examined are successively a proliferation of 
nuclei, fatty degeneration, and atrojihy. The question would 
still remain open, whether these changes result from im- 
pairment of nerve supply, or that the pathological change oc- 
curs primarily in the muscle itself. As more completely har- 
monizing with clinical observations, and affording a clearer and 
more definite conception of the cause and course of these mus- 
cular paralyses of the larynx, it seems fair to adopt the con- 
clusion that they are due, primarily, to certain changes having 
their inception in the muscles themselves. The muscles of the 
larynx are in a state of constant activity, more so, perhaps, than 
any other muscles of the body. They are liable to constant 
strain or over-use. They lie in contact with a mucous mem- 
brane which is extremely liable to be the seat of inflammatory 
action, which in a large proportion of cases becomes to an ex- 
tent permanent, in the form of a chronic catarrhal inflamma- 
tion. The muscles which lie in most intimate apposition with 
the mucous membrane of the larynx, and which are liable to 
most abuse in strained and prolonged use in talking, are prob- 
ably the tensors, namely, the thyro-arytenoid muscles, and, as 
is the case, it is these muscles which we would naturally sup- 
pose would become most frequently subject to im^jairment of 
function. In a large proportion of cases of chronic catarrhal 
laryngitis, we find that it is complicated with more or less im- 
pairment of tension, as shown in the so-called elliptical pa- 
ralysis of one or both sides. 

And so of any of the paralyses of single muscles, it is easier 
to explain their occurrence, by morbid processes occurring 
within the muscles themselves, than to suppose it possible that 
the individual fibres of the recurrent laryngeal nerves, which 
are distributed to a single muscle, could be paralyzed to the 
exclusion of the others. Certainly it is difficult to suppose 
that any pressure exercised on the nerve-trunk could so impair 
the conductivity of the fibres leading to a single muscle, as to 



PARALYSIS OF THR ABDUCTOR MUSCLES. 335 

destroy its function while the other fibres of the nerve remain 
intact. Nor, on the other hand, is it to be believed that any 
essential disease in the nerve-trunk itself could so differentiate 
the fibres as to select for destruction only those belonging to a 
single individual muscle. 



Unilateral Paralysis of the Crico-Arytenoideus Posti- 
cus Muscle. 

This muscle, arising from the posterior surface and sides of 
the cricoid cartilage, is inserted into the external angle of the 
base of the arytenoid cartilage. 

Its contraction draws the outer angle of the arytenoid 
backward, rotating the anterior angle of the cartilage, to which 
is attached the vocal cord outward, thus opening the glottis. 
The performance of this function, depends entirely on this 
muscle. In paralysis its function, as a glottis opener, is abol- 
ished, and the vocal cord falls into the median line. In pa- 
ralysis of the muscle of one side alone the symptoms are not 
prominent, nor is the condition necessarily a grave one ; but 
where both the muscles are paralyzed, as already stated, the 
condition is attended with the greatest possible danger to life. 
The subjective symptoms of unilateral paralysis of this mus- 
cle present no features which, as a rule, would even call at- 
tention to the larynx, unless, as is usually the case, there be a 
laryngeal catarrh, when, of course, the symptoms would point 
to that affection rather than to the paralysis. There is no 
dyspnoea, the voice is not affected, adduction and tension 
upon which normal phonation depends being not markedly 
impaired, -although tension of the cord ma}^ be slightly inter- 
fered with from the abolition of that function of the paralj^zed 
muscle, which consists in its holding the arytenoid cartilage 
firmly in place, affording a fixed point for the contraction of 
the thyro-arytenoideus — the tensor muscle of the cord. The 
glottis is somewhat narrowed, hence in labored breathing, re- 
sulting from any exertion, there may be a slight stridor on 
inspiration ; as a rule, however, this is not noticed. 

On examination of tlie larynx in this condition the cord of 
the paralyzed side will be noticed to lie quietly and at rest in 
the median line, while its fellow of the opposite side moves 



336 NEUROSES OF THE LARYNX. 

with the acts of inspiration and phonation thronghout its nor- 
mal arc. While the cord, however, lies motionless, the aryte- 
noid cartilage itself will be noticed with each act of phonation 
to tilt somewhat toward its fellow of the opposite side under 
the action of the arytenoideus muscle. 

The appearance of the larynx in this condition, in the act 
of inspiration, will be seen as above. The position of the cords 
in the act of phonation will, of course, be normal. The only con- 
dition with which it is liable to be confounded is that of recur- 
rent laryngeal paralysis. Careful examination, however, will 
reveal the characteristic differences between the two affections. 
The prominent distinctive feature being, that in the affection 
under consideration the cord lies in the median line, while in 
the other it assumes the cadaveric position. While not essen- 
tially a grave condition in itself, it is probable that in many 
cases the paralysis of one muscle may be a forerunner or warn- 
ing that the other muscle may become affected, in which case 
the affection becomes one of the greatest gravitj^. It is not 
intended to give the impression that unilateral paralysis, as a 
rule, precedes bilateral, but that this may be the occasional 
sequence of events has come within the writer s personal obser- 
vation. 

In the very large proportion of cases this form of paralysis 
in the larynx is due to syphilis. Occasionally it is met with 
in laryngeal phthisis, and also in cancer of the larynx. In 
these cases the direct local action of the source of the paraly- 
sis is easily traced, in either pressure upon or infiltration of the 
muscular tissue, and thereby the destruction of its functional 
activity. 



Bilateral Paralysis of the Crico-Arytenoibei Postici 
Muscles. 

This disease presents so many points of extreme Interest 
that I prefer to devote a separate chapter to its fuller con- 
sideration. I regard it as differing in its pathology from those 
we are now considering, in that it is not always purely of a 
myopathic origin, but is rather of a central origin. For this 
reason, therefore, its consideration is best deferred. 



PAKALYSIS OF THE ADDUCTOR MUSCLES. 337 



Unilateral Paralysis of the Crico-Arytenoideus Later- 
alis Muscle. 

This is an extremely rare affection, and in tlie few cases 
reported there seems to be an element of doubt as to the cor- 
rectness of diagnosis. That it may occur, however, is un- 
doubtedly true. The function of this muscle being to draw 
the vocal cord toward the median line, the effect of its paralysis 
would be that the cord would lie motionless in a state of ex- 
treme abduction, that is, against the lateral wall of the larynx. 
As a result of this, and the consequent inability of its fellow to 
approach it for the purpose of phonation, the voice would be 
lost, otherwise the symptoms would not be prominent. There 
would be no dyspnoea, other tlian something of the expiratory 
dyspncBa already referred to, with a partial inability to cough. 
An examination will show the condition above described. The 
condition with which it may be confused is that of recurrent 
laryngeal paralysis ; the prominent point of distinction be- 
tween the two affections is in the extent to which the paralyzed 
cord is abducted. In addition to this there is paralysis of ten- 
sion, which does not exist in the affection under consideration. 
The voice is, as a rule, lost in this affection, while but moder- 
ately impaired in the recurrent laryngeal paralysis. 



Bilateral Paralysis of the Crico-Arytenoidei Later ales 
Muscles. 

In this affection, botli adductor muscles of the cord being 
paralyzed, the cords lie in a state of extreme abduction, name- 
ly, against the sides of the thyroid cartilages. The glottis tlius 
becomes widely opened, the voice is lost completely, the abil- 
ity to cougli is destroyed, and the expirator}- dyspnoea above 
alluded to becomes a prominent s^nnptom of the affection. It 
is an extremely rare disease, but easily recognized from the 
position of the cords, which on inspection will be seen assum- 
ing the position of extreme abduction. The onl}^ affection witli 
wliich it may be confounded is that of double paralysis of the 
recurrent laryngeal nerves, and spasm of the abductors, if 
such an affection ever occurs, which is extremely doubtful. 
22 



338 np:u ROSES of the larynx. 

What was said in regard to tlie differential diagnosis in connec- 
tion with the unilateral paralysis of this muscle applies equally 
well to the bilateral affection. 



Bilateral Paralysis of the Thyro-Arytenoidei Mus- 
cles. 

This disease is sometimes spoken of as simple paralysis of 
the tensors, and also elliptical paralysis of the cords. It is 
still apparently an open question what the true function of 
this muscle is, some writers regarding it as a laxator muscle, 
in that its contraction diminishes the distance between the 
arytenoid cartilage and the receding angle of the thyroid. 
What possible end could be subserved, by the accomplishment 
of this act of relaxing the vocal cords, I never have been able 
to comprehend. Simple relaxation of muscular effort will 
accomplish all that is desired in this direction, w^hile the idea 
that muscular contraction need be brought into play to relax 
the vocal cord, so far complicates the problem of the true func- 
tion of the laryngeal muscles that it seems to me that it liad 
best be abandoned. The true function of the thyro-arytenoid 
muscle is that of a tensor of the cord. The principle on which 
it acts is best shown by the homely illustration of a rope 
stretched between two fixed points ; if it be wetted the fibres 
become swollen and laterally distended, thus stretching the 
rope more tensely. The nerve-current acts upon the fibres of 
the thyro-arytenoid muscle in exactly the same manner as the 
water upon the stretched rope. It should be remembered, of 
course, that this muscle is stretched between two fixed points, 
for although the arytenoid cartilages are movable, they are 
rendered to a great extent motionless in the act of phonation 
by the contraction of the crico-arytenoidei postici muscles. 
The anterior insertion of the muscle in the receding angle of 
the thyroid cartilage is, of course, a fixed point. The true func- 
tion of the thyro-arytenoideus muscle, then, is that of a tensor 
of the cords, and under its action the cord is endowed with the 
property of a wide range of vibrations which gives it the power 
of regulating the pitch of the voice. 

Owing to the intimate relation between the mucous mem- 
brane lining the larynx and the thyro-arytenoideus muscle, it 



PARALYSIS OF THE TENSOR MUSCLES. 339 

is extremely liable to have its function impaired by any inflam- 
mation which inv^olves the larjaigeal membrane, so that a not 
infrequent cause of imjDairment of function, assuming the form 
of a paresis or paralysis of this muscle, lies in a chronic laryn- 
geal catarrh. 

Another frequent source of trouble lies in overstraining by 
prolonged use of the voice or a too labored attempt at main- 
taining it at high tension. Paralysis of tension occurs in con- 
nection with recurrent larj^ngeal paralysis, and may also be 
indirectly a result of impairment of the general health as in 
anaemia, etc. 

The symptoms of this affection consist mainly in impair- 
ment of the voice, according to the extent to which the muscle 
is affected. This may be simple lowering of register and slight 
huskiness of the voice, but never aphonia. The ability to strike 
the high notes is lost, and the voice also becomes extremely 
weak, and the sufferer unable to endure any prolonged use of it, 
it tires easily. In extreme cases there is a peculiar hesitancy 
in the voice, especially in the utterance of the aspirates, such as 
lioiise^ etc. In attempting these words the sufferer will make 
several futile efforts before he is able to bring out the clear 
note ; this may amount occasionally to almost a stuttering voice. 
The cause of this is very simple — the result of the paralysis of 
the tensors is, that while the arytenoids are approximated and 
the cords brought into apposition for phonation, the instant 
that the current of air from below impinges upon the under 
surface of the cords to force itself between the narrow chink in 
order to throw them into vibrations, it finds them in such a 
llaccid and relaxed condition that they bulge out and open, 
allowing the air to escape through the elliptical aperture thus 
made without being thrown into phonative vibrations, and it is 
only after several ineffectual efforts that they become sufficient- 
1}^ tense to give forth the desired sound. An examination with 
the laryngeal mirror shows this condition of things very clear- 
ly. The mirror being in position the patient should be directed 
to i^honate, when, instead of the straight and narrow chink of 
the glottis with the cords in a parallel position, they will be 
bowed out, leaving an elliptical opening between them. This 
appearance is easily recognized and characteristic. The posi- 
tion whicii the cords assume is shown in Fig. 133. This elliptical 
opening extends the full length of the vocal cords. One would 




340 NEUROSES OF THE LARYXX. 

suppose that under the action of the adductor muscles the vo- 
cal processes of the arytenoid cartilages would be brought into 
apposition, and that this relaxation would 
only be shown extending from these pro- 
cesses to the anterior insertion of the 
cords. As a matter of clinical observa- 
tion, however, the relaxation seems to ex- 
tend the whole length of the cords, from 
Fxa. m_Positio„ Of the ''^^'''^' ^^'^ ""S'^^^ i"^«i' ^^'^^ the action of 
^^^^^^^<^,'^:^ t^i^ thyro-arytenoid muscle, as well as the 
cai paralysis. (From Macken- crlco-ary teuoldeus lateralis, is essential in 
bringing the vocal cords into parallelism, 
and that while the former muscle rotates the arytenoid carti- 
lage on its axis, and brings the vocal process toward the median 
line, the contraction of the latter muscle is necessary to bring 
the cords into perfect parallelism. 



Unilateral Paralysis of the Thyro-Arytenoid Muscle. 

From what has been said before in regard to double paraly- 
sis of the tensor muscles, little need be said in regard to paraly- 
sis of the single muscle. This not infrequently occurs on one 
side of the larynx as a result of local causes, or, as has been 
stated above in connection with the paralysis of the other mus- 
cles, in recurrent laryngeal paralysis. 

The symptoms would be much the same, only in a less de- 
gree, as those which accompany the bilateral affection. The 
condition is easily recognized, the cord of the paralyzed side 
bowing out in the manner above described, while on the mobile 
side of the larynx the cord assumes its normal position in 
phonation. 



Paralysis of the Arytenoideus Muscle. 

Owing to its exposed situation, and from the fact that the 
arytenoid commissure is the frequent seat of catarrhal affec- 
tions, ulcers, etc., one would suppose that the arj^tenoideus mus- 
cle would be the frequent seat of jjaresis or paralysis. As a 
matter of actual observation, however, it is extremely rare. 



TREATMENT OP PARALYSIS. 341 

When occurring it is due to a catarrhal affection, generally of 
an acute character. The function of this muscle being to ap- 
proximate the arytenoid cartilages, its paralysis necessarily 
abolishes this function while the adduction of the cords is still 
accomplished by the action of the crico-arytenoidei laterales 
muscles. As a result of this, when the cartilages are rotated, 
their vocal processes are brought into apposition, and the cords 
into parallelism from these processes to their anterior inser- 
tion ; but the cartilages not being approximated, a triangular 
ojDening is left posteriorly between them, as shown in Fig. 134. 
Hence, in the act of phonation, while the 
anterior two-thirds of the cords are thrown /^^^\ 

into vibration, the air escapes through this ' - ' '/ ^ ■ --». 
triangular opening ; the voice becomes '' 

hoarse, lowered in pitch, and phonation ^*\ 
is accomplished with considerable effort, ' ^^^^^^^^ 

the voice soon tiring. Paralysis of the f,,. U4 S.r.^ysi. ot ti.e 
arytenoid muscle should not be confound- ThftSuTar oSng feS 
ed with those causes which produce me- ^^1^^°''''^ processes. "(Macken- 
chanical interference with the approxima- 
tion of the cartilages, such as glandular infiltration, thicken- 
ing of the arytenoid commissure, as in the first stage of laryn- 
geal phthisis, the presence of tumors, ulcerations, etc. A 
careful examination will always reveal the presence of these 
conditions, and a mistake in diagnosis need not occur. 



Treatment of Paralysis in General. 

As regards the treatment of those affections which depend 
upon defective innervation from pressure or other causes, such 
as recurrent laryngeal paralysis, it is of importance that the 
origin of the disease should be recognized and treated, as of 
course tliere is no especial indication for local treatment in the 
laiynx if an aneurism or cancer is pressing on the recurrent 
nerve. In these cases the principal value of the recognition of 
the laryngeal affection lies in the aid which it gives to the diag- 
nosis of the original disease which gives rise to it, and in the 
fact that the physician's attention is thus called to the possi- 
bility of an aneurism or other tumor pressing on the trunk 
of the nerve, and which a careful exploration may reveal. 



342 NEUROSES OF THE LAPwYNX. 

In those cases in which the cause of the affection cannot be 
discovered, it becomes a nice problem to determine the proper 
course to pursue. Tliat syphilis will produce these affections is 
a matter of observation, though just what lesion of syphilis is 
always responsible for the occurrence it is difficult to sa}^, and 
yet if a S3^philitic history can be obtained, or even if it is not 
satisfactoril}^ obtained, it is justifiable, where there is the slight- 
est suspicion of the infection, that the patient should be placed 
under antisyphilitic treatment. At the same time the tendency 
to atrophy of the muscles should be counteracted by proper 
measures. All muscles at rest from paralysis or any other* 
cause, as we know, soon undergo fatty degeneration and atro- 
phy. If there is hope, then, that the lesion of the nerve-trunk 
may be remedied, endeavor must be made to preserve the mus- 
cular structures of the larynx in a condition of health until 
that end is attained. For this purpose the use of the Faradic 
current should be used, as noted further on. In those cases 
in which no assignable cause can be discovered, in which no 
specific history can be obtained, the cause of the affection re- 
maining in obscurity, it simply remains to correct any ten- 
dencies that ma}^ exist, remove any possibly exciting causes 
of nervous trouble, such as scrofula, the tuberculous diathesis, 
anaemia, malaria, etc., and correct as far as possible the gen- 
eral condition. In the myopathic paralyses, viz., those affec- 
tions in wiiich the individual muscles are paralyzed and in 
which the disease has its origin in the muscular structures 
themselves, the treatment must necessarily be mainly local, 
though, of course, here also it is of importance to correct gen- 
eral conditions which may present indications for treatment, 
and build up the general health as far as required. In addi- 
tion to this we possess two remedies whose use oftentimes 
promises good results, namely, strychnine and electricity. 
Strychnine should be administered hypodermically from the 
^ to the gV of a grain, daily, in preference to its internal ad- 
ministration ; but where its hypodermic administration cannot 
be carried out it should be given internally. 

Electricity. — This, above all other remedies, is one wiiich 
promises the best results in these local paralyses. Of the gal- 
vanic and Faradic currents the latter should receive the prefer- 
ence, although writers often recommend that they should be 
alternated. In applying the electric current, the more nicely 



TREATMENT OE PARALYSIS. 



343 



and perfectly the current is localized in tlie paralyzed muscle, 
the better the results that may be expected. For this nicer 
localization of the current a number of instruments have been 
devised, by vrhicli the application may be made directly to the 
affected muscle by means of electrodes introduced into the 
laryngeal cavity. The principle on which these instruments 




Fig. 135. — Madienzie'-s laryngeal electrode and necklet. The necklet is connected with one pole of 
the battery, while the handle is connected with the other pole. The terminals of the electrode are a 
metal ball, or a spade-shaped terminal for special application to the crico-arytenoideus posticus muscle. 

operate is shown in Fig. 135. This illustrates Mackenzie's 
laryngeal electrode, which is connected with one pole of the 
battery, the other pole being connected with an electrode which 
is either held in the hand of the patient, or better still, against 
the skin over the larynx, by means of the necklet shown in the 
figure. An electrode having been introduced into tlie laryn- 
geal cavity, and as near as possible upon the muscle which it 




Fig. 130.— Fauvel's nrodification of Mackenzie's laryngeal electroile. The instrument terminates in 
two metal balls. The current passes from one ball to the other, when the circuit is closed, and the in- 
strument is applied m the laryngeal cavity. The cut shows one pair of terminals arranged antero-pos- 
teriorly, and the other transversely. 

is desired to galvanize, tlie current is closed by pressing witli 
the forefinger on the little lever shown in the cut, by which 
the electric circuit is closed. This electrode may either be 
mounted with a sponge or with an insulated metal ball. In 
Fig. 13(5 is shown Fauvel's modification of this instrument, in 
whicli the two poles are united in one instrument, the current 



344 NEUROSES OF THE LARYNX. 

passing between the two metal balls at the end of the electrode, 
thus enabling the operator to conline the current to a single 
muscle. The use of these electrodes for the nice localization of 
the current, requires rather deft manipulation and also a cer- 
tain degree of tolerance on the part of the patient which pre- 
vents their use being of universal application ; hence, it will 
oftentimes be necessary to abandon or postpone the attempt to 
apply the current within the larynx. Promising results may 
often be obtained by making applications over the thyroid 
cartilage, passing the current directly through the larynx by 
means of sponges held upon this region, or what is better still, 
applying one pole to the recurrent laryngeal nerve at the side 
of the neck, while the other is held over the thyroid cartilages 
in front. In making applications of electricity, the current 
should not be too strong, or the sittings prolonged. 

Hysterical Aphonia. 

This term is used to designate a form of aphonia which Ave 
occasionally meet with, characterized by a complete loss of 
voice, in which there is deficient muscular action, due to no 
pathological lesion but purely functional in character. It is 
sometimes designated as hysterical paralysis of the vocal 
cords, and again as functional paralysis. The idea that this is 
a sham paralysis, or that it arises in any attempt to deceive, 
should not be entertained ; and yet there is no genuine paralysis, 
no pathological condition, no loss of contractility in the mus- 
cular structures, and no loss of conducting power in the 
nerves. The true nature of hysteria I do not propose to dis- 
cuss, or the character of the numberless phases which it as- 
sumes, but simply to asseverate that, as far as the patient is 
concerned, hysterical paralysis is a true paralysis for which 
the sufferer is not directly responsible, and that, whereas it has 
the appearance of being a counterfeit, the patient cannot con- 
trol it. The important point, and the one to be emphasized in 
the consideration of this affection is, that while the condition 
is one that can always be assumed under voluntary effort, it is 
still one which is assumed by the patient under the influence 
of this strange psychical condition, or by whatever other term 
we may choose to designate it, and not one which the patient 
wilfully assumes with the desire to deceive or excite sympathy. 



HYSTERICAL APHONIA, 345 

Furtliermore, hysterical aplionia or paralysis never counter- 
feits any of those forms of paralysis which cannot be assumed 
by voluntary effort. The respiratory movements of the vocal 
cords are involuntary, while the movements of phonation are 
voluntary. Abduction of the cords being purely an involun- 
tary motion, and occurring only during the act of inspiration, 
and never as a purely voluntary act, paralysis of the abduc- 
tors is rarely met with as a functional or hysterical paralysis. 
Again, both the phonative and respiratory movements in the 
larynx are symmetrical ; hence, whether the act be voluntary 
or involuntary, a unilateral paralysis of the vocal cords can 
never occur as a hysterical or functional affection. The form 
which the disease under consideration assumes is that of im- 
perfect approximation of the cords, resembling somewhat the 
condition which we meet with in double paralysis of the recur- 
rent nerve. The patient does not bring the vocal cords into 
sufficiently close approximation for phonation ; she does, how- 
ever, adduct the cords somewhat, and the sound produced 
by the passage of air through the partially closed rima giot- 
tidis is thrown into articulation by the lips and tongue, etc. ; 
the loud voice is lost, and the patient simply communicates 
in a whisper. The affections which the disease under con- 
sideration may simulate are, subacute or chronic laryngitis, 
those cases of aphonia which are due to mechanical interfer- 
ence with the proper closure of the cord, by thickening of the 
arytenoid cartilages or commissure, and bilateral paralysis of 
the recurrent lar3aigeal nerves. Subacute or acute laryngeal 
catarrh is often accompanied by complete loss of voice ; but 
the laryngeal examination will reveal the complete mobility 
of the cords, and in addition, the source of the aphonia in 
the catarrhal inflammation of the mucous membrane lining 
the larynx, accompanied by swelling of the membrane covering 
the cords, which has resulted in loss of voice simply from the 
thickened condition of the cords. If the arytenoids or the com- 
missure are so far swollen or infiltrated as to offer a mechan- 
ical obstacle to the proper closure of the cords, this will be 
easily recognized. In double paralysis of the recurrent laryn- 
geal nerves all the muscles of the larynx are completely para- 
lyzed, the cords are absolutely motionless, in a position mid- 
way between extreme adduction and abduction, namely, in the 
so-called cadaveric position. This position of the vocal cords 



346 NEUROSES OF THE LAEYNX. 

cannot be assumed or simulated, for while under voluntary 
effort the cords may be partially approximated and brought 
into the same position of half-way approximation, or into the 
cadaveric position, the instant that inspiration occurs, the glot- 
tis will be widened under the involuntary movement, which al- 
ways attends the inspiratory act, and the movement can be seen 
to take place. This is the characteristic condition which we 
meet with in hysterical or functional paralj^sis ; it is always a 
bilateral affection, and always assumes the form of incomplete 
closure of the glottis. It may not improperly be designated 
as bilateral paresis of the adductor muscles, only that this 
would involve the idea of some genuine lesion of the nerve- 
trunk or the muscular structures which, as before stated, does 
not exist. Simon has reported a case of hysterical or func- 
tional paralysis of the abductor muscles, in which the paraly- 
sis seemed complete, producing that very grave condition to 
be described under the head of bilateral jmralysis of the crico- 
arytenoidei postici muscles. The apparent dyspnoea was so 
great that preparations were made to perform traclieotomy 
when, according to the account, the patient suddenly spoke, 
and the condition disapjDeared. 

That hysterical paralysis may assume the character of this 
serious affection is undoubted, as any one can demonstrate on 
his own person by imitating an inspiratory dj^spnoea, closing 
the glottis, and attempting to inspire, producing a nois^" strid- 
ulous inspiration ; but that this can be kept up for any length 
of time is questionable. In Simon's case, however, there Avas a 
false color in the picture, in that there was aphonia in connec- 
tion with the paralj'sis of abduction, and this, as we know, 
does not occur in the disease referred to ; the voice, usually, 
is nearly normal. A careful study of the larynx, will serve 
to clear up the diagnosis of these cases, and enable the phy- 
sician to determine with a considerable degree of certainty that 
the aphonia is a functional disorder, and not due to any path- 
ological lesion, simply by exclusion ; for, as a rule, the laryn- 
geal image does not and will not present a complete picture of 
any of the forms of genuine paralysis. In addition to this 
there will be the usual accompanjing general evidences of the 
hysterical temperament, which we all recognize and which it 
is not necessar}?^ to describe here. It should be added also that 
cough is present in hysterical aphonia, while in genuine pa- 



HYSTERICAL APHONIA. 347 

ralysis of the adductors, it is entirely lost ; the possibility of a 
congh being dependent on the ability to close the glottis, 
whether this closure be by voluntary or involuntary muscu- 
lar effort. Furthermore, the onset of this form of larj^ngeal 
paralysis is quite sudden. It comes on without any previous 
warning whatever, and with no symptoms which, have in any 
way called attention to the larynx. Ordinarily a patient 
awakens in the morning and discovers that she cannot talk. 
The crucial test, and one which can be relied on with great 
certainty for diagnostic purposes, is the administration of an 
anaesthetic. Where there is any doubt as to diagnosis ether 
should be given, when, as a rule, it will be found daring the 
second stage of anaesthesia, namely, that of excitement, the pa- 
tient will break into a very satisfactory use of the voice. It is 
unnecessary to say that the victims of this disorder are women 
from fifteen to forty-five years of age, and most frequently un- 
married, or those in whom the sexual life has been perverted. 

Treatment. — The judicious management of a case of hyster- 
ical aphonia, as that of any other form of hysteria, requires far 
less special skill than good sense. It is utterly unsafe to treat 
these cases as unreal or as dishonest. As far as the patient if? 
concerned, the paralysis is a genuine paralysis, as much so as 
if the trunk of the nerve were destroyed ; and the recognition 
of this fact is of the utmost importance in the successful man- 
agement of the case. Hence, within bounds it is not only justi- 
Hable but even necessary to treat it as a real paralysis. In 
addition, therefore, to the. rem oval of any exciting causes, such 
as uterine disease, etc., resort should be had to local treatment ; 
the end in view is to convince the patient that she can use her 
voice. It is not always an easy matter to do this without 
resorting to some method of removing the morbid condition 
which she believes to exist. Hence, one waj^ of accomplishing 
this is by resort to local measures of treatment, securing the 
patient's confidence and assuring her that such and such 
measures will be attended with success, and that at some desig- 
nated time the complete restoration of the voice will be effected. 
In Simon's case, previously alluded to, a profound impression 
was made on the patient by the preparations for tracheotomy, 
with the result of completely removing the paralysis. This 
procedure may be successfully imitated in any manner which 
the ingenuity of the physician may devise. . 



CHAPTER XXL 

NEUEOSES OF THE LAEYNX (Continued). 

Bilateral Paralysis of the Abductor Muscles of the 
Larynx. 

The crico-arytenoidei postici muscles, whose special func- 
tion consists in their action as glottis- openers, possess an inter- 
est which is somewhat unique, both from a physiological point 
of view, and from the fact that' any morbid condition which 
involves an abolition of their healthful activity is attended 
with the gravest and most serious consequences. They arise 
from the posterior surface of the cricoid cartilage, and are in- 
serted into the outer angle of the arytenoid. By their con- 
traction they rotate the arytenoids outwardlj^, thus separating 
the vocal cords and opening the rima glottidis. This function 
lies entirely and exclusively in this pair of mussles, and Na- 
ture has provided no other means by which the glottis can be 
opened. This so-called respiratory function of the larynx is 
brought into play with every act of inspiration, rendering this 
pair of muscles among the busiest in the body, in that they 
are kept in a state of constant activity from the first breath 
drawn in infancy until death puts an end to all functions. 

By the peculiar conformation of the vocal cords, while ex- 
piration is purely passive, and the exit of the current of air is 
permitted without muscular action on the glottis, the entrance 
of the current of inspired air is arrested unless the cords are 
separated by the action of the glottis-openers. The upper sur- 
face of the vocal cords is broad, flattened, and somewhat de- 
pressed or excavated, in such a manner that the current of 
in-going air, striking them from above, while the cords are 
approximated, tends to throw them still closer together, in a 
way very much resembling the action of the semilunar valves 
of the heart. In other words, the rima glottidis is more or 
less completely closed to the entrance of air by the valve-like 



BILATEKAL PARALYSIS OF THE ABDLTCTOES. 



349 



action of tlie vocal cords, unless this little pair of muscles 
open it by their contraction, as shown in Fig. 137. 

This action of the glottis-opening muscles is purely invol- 
untary, in that it is entirely beyond the control of the will, 
and also that it must necessarily go on during sleep, as well as 
during waking hours. It is also 
reflex, and does not take place 
except under the influence of 
an in-going current of air im- 
pinging upon the larjaigeal cav- 
ity, for, as we know, after the 
operation of tracheotomy, it 
ceases, and, if we examine the 
larynx of a patient wearing a 
tracheal tube, we find the cords 
at perfect rest. Reasoning from 
analogy, we are Justified in the 
conclusion that this glottis- 
opening function of the larynx 
is presided over by an inde- 
pendent ganglionic centre, situ- 
ated in the brain, but which 
neither physiological experi- 
ment nor pathological investi- 
gation has as yet been able to 
locate. Since the introduction 
of laryngoscopy there have 
come within our notice a group 
of grave laryngeal affections, characterized by a peculiar set 
of symptoms, which laryngoscopic investigation shows to be 
due to the abolition of this glottis-opening action in the larynx 
during inspiration. 

Symptoms. -^Vnd.QV the name of bilateral paralysis of the 
abductors of the larynx, or of the crico-arytenoidei postici 
muscles, there have been reported a number of cases in which 
the symptoms present something like the following picture : 
The i)atient begins to suffer from a peculiar d^^spnwa, in which 
the difficulty attends the inspiratory act entirely, and not the 
expiratory act. Tins is generall}^ spoken of as ins]nratory 
dyspncea. Accompanying this constant state of dyspncea, the 
l)atient also suffers from exacerbations, or spasmodic attacks, 




Fig. 137. — TransversR section of the larynx : 
rt, epiglottis ; 6, hyoid bone ; c, thyroid cartilage ; 
rf, ventricular band, or false cord : e, ventricle of 
the larynx ; /, rima glottidis ; g, trne vocal cord ; 
A, thyro-arytenoid mnscle ; i, cricoid cartilage ; J, 
first ring of the trachea. (Bristowe.) 



350 ?^EUROSES OF THE LARTXX. 

recurring with more or less frequenc}^, in which all the symp- 
toms are markedly aggravated, and which may excite the 
gravest apprehension, according to the extent of the interrup- 
tion to the entrance of air into the lungs. Accompanying this 
apparently very grave laryngeal obstruction, it is noticeable 
that the voice is not affected or is but little impaired. This 
feature of the disease often seems an extremely surprising one. 
Remembering, however, the morbid condition "which gives rise 
to the affection, we can easily understand why this should be. 
The grave sj^mptoms of the disease occur in connection with 
inspiration, wiiile phonatiou is accomplished under the action 
of those muscles wiiich are unimpaired, and during the act of 
expiration. 

These attacks of inspiratory dyspnoea, mild at the onset of 
the affection, and not giving rise to any serious apprehension, 
gradually become more serious in character ; and, in addition 
to this, the spasmodic attacks recur with greater frequency 
and become of a more urgeiit tj-pe, until finally, unless the 
disease is arrested, tracheotomy becomes necessar}^, and, fur- 
thermore, the wearing of the tracheal canula during life. 
Tliis, however, would simply indicate that, wiiere a case has 
gone on to such an extent that tracheotomy is imperatively 
demanded, the muscles have become so disorganized that all 
hope of restoring them to health}^ action is lost ; and, apart 
from tliis healthy action, Ave possess no means by which the 
entrance of air can be secured through the larynx. Hence, 
tracheotomj^ becomes an absolute necessity. The glottis is 
closed, and it should be added that this closure of the glottis 
is not due alone to paralysis of the abductor muscles, but the 
essential gravity of the affection lies in the fact that the crico- 
arytenoidei laterales muscles retain their integrity ; tliat is, 
paralysis of the abductor muscles is not alone sufficient to pro- 
duce the affection, but the adductor muscles, being unopposed 
in their action, rotate the arytenoid cartilages inward, and 
thus bring the cords into apposition. A perfect closure is 
thus accomiDlished, and a total arrest of the entrance of air, by 
the valve-like action of the vocal cords, which is only manifest- 
ed of course when the cords are in apposition. Hence, it seems 
to me, there can be no doubt that, if w^e have both the muscles 
paralj^zed, as is the case in paralysis of both recurrent laryngeal 
nerves, the condition which I have described does not occur. 



BILATERAL PARALYSIS OF THE ABDUCTORS. 



351 



Examination. — If a laiyiigoscopic examination be made 
the appearance will be striking and cliaracteristic. The cords 
will be found lying in the median line, in a state of parallel- 
ism, and almost entirely motionless, the chink of the glottis 
presenting a narrow slit-like opening from one to two lines in 
extent (see Fig. 138). The cords, however, are not absolutely 
motionless, for, as already noticed, the voice is not, as a rule, 
markedly impaired ; hence, during the act of phonation, the 
slight movement necessary to bring the cords into apposition 
will be noticed. There will also be seen a slight separation of 
the cords during a forced expiration (see Fig. 139). This is 
due entirely to the action of the current of air, and not to any 
muscular effort. 

There maj^, in cases, be seen a condition of hj^^pereemia, or 
even catarrhal inflammation of the mucous lining of the larynx, 
but this is not a condition which in any way belongs to the 
disease. 



r 




Fin. 1.38. — Bilateral paralysis of the abductoi's. Position of the cords in inspiration. 
Fig. 139. — Bilateral paralj'sis of the abductors. Position of the cords in expiration. 



There are so many features of this affection which are in- 
teresting, that I have thought it well to add here the histories 
of four cases which have come under my own observation, to- 
gether with a resume of the cases which have been reported by 
others. 



Case I. — Richard D.owliug, Irish, aged forty-six, a sailor, came to the clinic at 
Bellevue in February, 187."i, wiih the following history : Fifteen years ago he had a 
primary sore, but never had any secondary or tertiary developments of syphilis, other 
than alopecia and osteocopic pains. For a year before coming under notice, he had 
been suffering from gradually increasing shortness of breath, and within two months 
had been subject to attacks of dyspnoea, recurring with greater frecpiency, and at 
times of an exceedingly alarming character. An examination made at this time by 
Dr. Bangs, and also by myself, revealed complete jiaralysis of the abductor muscles 
of both sides. The cords were quite motionless, with but a narrow opening between 
them. There was also a considerable degree of chronic inllamination of the mucous 



352 NEUROSES OF THE LARYNX. 

membrane lining the larynx. A careful examination of the chest, repeated several 
times, and made with special reference to the possibility of aneurism, revealed no 
morbid condition. Various plans of treatment were carried out in this case, espe- 
cially the administration of large doses of iodide of potassium, but without any effect 
on the symptoms or the laryngoscopic appearances. He made a number of visits at 
the dispensary, and several times during the examinations he had attacks of dyspnoea, 
which were of so grave and alarming a character that a fatal issue was feared. On 
the 21st of March, 1875, la^yngotomy was done by Dr. Katzenbach, the tube being 
inserted through the crico-thyroid membrane. Aside from ulcerations occurring on 
the posterior wall of the trachea, produced by the irritation of the tube, and re- 
sulting in fungus-like granulations, which bled occasionally, the case presented 
no new symptoms, and the tube was worn until death occurred, on the 28th of 
November, 1877. He died with symptoms of spinal meningitis. No autopsy was 
permitted. 

Case II.— In May, 1878, I was asked by Dr. H. P. Walker to see a patient in 
Bellevue Hospital, suffering from urgent dyspnoea. I found the man, a sailor, aged 
forty, suffering from the peculiar inspiratory dyspnoea which suggested bilateral pa- 
ralysis of the abductors. A laryngoscopic examination showed the peculiar motion- 
less condition of the vocal cords, with marked hyperEemia of the mucous membrane. 
His voice was husky, but not lost. He gave a clear history of having contracted 
syphilis ten years before. A year before I saw him he had begun to suffer from 
moderate shortness of breath, with oscasional attacks of dyspnoja of an apparently 
spasmodic character. These attacks recurring with greater frequency and severity, 
he came to Bellevue, where I saw him on the day after his admission. I advised 
tracheotomy, but, the immediate attack subsiding very soon, it was not done, and 
the man left the hospital a few days afterward suffering from mere shortness of 
breath. A few days subsequently, another paroxysm coming on, he was taken to St. 
Luke's Hospital, where tracheotomy was performed, after which he was subjected to 
treatment by electricity, in connection with the internal administration of iodide of 
potassium, with an apparent slight improvement, as often occurs in these cases. It 
was delusive, however, and he subsequently left the hospital with the tube in, and 
was lost sight of. 

Case III. — On August 9, 1880, I was requested by Dr. J. A. McCreery, of this 
city, to see a patient with the following history : Mr Q., Irish, aged forty-eight, a 
laundress, of good family history, had complained for over a year of a feeling of dis- 
comfort in the throat, which caused no special uneasiness until April, 1880, when 
she began to have some difficulty in swallowing. At this time there was some in- 
duration of the cervical glands, with oesophageal obstruction, as evidenced by the 
passage of the bougie ; but the laryngoscopic examination revealed no morbid condi- 
tion. Early in July, however, there was noticed, projecting from the orifice of the 
oesophagus, an irregularly nodulated mass, jjresenting the characteristic appearances 
of epithelioma, serving to confirm the suspicion already entertained that the 
disease was epithelioma of the oesophagus. On August 6, 1880, Dr. McCreery re- 
quested me to see her, and my diagnosis was only confirmatory of his. I saw the 
patient a number of times, and observed the progressive increase of the tumor, 
together with a deficient action of the glottis- opening muscles, which seemed to be 
more marked each time I saw her. This was also evidenced by recurring attacks of 
dyspnoea, which were of a spasmodic nature, and which soon became of an alarming 
character. I last saw her on September 27th. At this time the action of the ab- 
ductor muscles seemed to be completely abolished, and, as the dyspnoea was quite 
marked, I advised that tracheotomy be performed. Preparations were being made for 



BILATERAL PARALYSIS OF THE ABDUCTORS. 353 

the operation, when she suddenly expired, early on the morning of September 29th. 
Death resulted from the paralysis, as the tumor in no way encroached upon the 
larynx. The paralysis in the case was due, of course, to the infiltration of the mus- 
cular fibres by the malignant growth. 

Case IV. — E. C, a Frenchman, aged forty -two, a merchant, consulted me, 
August 19, 1880, at the request of Dr. A. Borde, of New Orleans, and gave the fol- 
lowing history. He had always enjoyed good health, with the exception of occa- 
sional attacks of jDalpitation of the heart, which he had been told was due to an 
enlargement of that organ. The pulse was always quite rapid, but his heart trouble 
had never given him any uneasiness. He had always lived a perfectly temperate 
life, and indulged in no excesses. He was not in the habit of using tobacco, and 
never drank spirituous liquors. For ten years he had been subject to occasional 
attacks of dyspnoea, which were always of an inspiratory character, inspiration being 
attended by a noisy stridor, while the attack lasted, which was generally from two 
to five minutes only. There was no marked difficulty in deglutition, yet he was com- 
pelled to swallow quite slowly, or the act would bring on an attack of dyspnoea. He 
had formerly been fond of singing, but had been compelled to abandon it, as the 
voice had become weakened, and tired easily. Moreover, prolonged use of the voice 
or loud talking was apt to bring on the spasm. The uvula and the tonsils had been 
removed, but with no result. Physical examination of the chest showed the lungs 
perfectly healthy. The heart was moderately enlarged. Pulse, 96. 

An examination of the larynx revealed the characteristic appearance of bilateral 
paralysis of the abductor muscles. The cords were in a state of parallelism, about 
one line apart, and quite motionless. The mucous membrane lining the larynx was 
in a state of chronic catarrhal inflammation, and somewhat relaxed. In addition to 
this, there was a markedly relaxed condition of the vocal cords, constituting the so- 
called elliptical paralysis, or paralysis of tension. 

The singular feature of the case was the long standing of the paralysis without 
tracheotomy having become necessary. This is partially accounted for by the exist- 
ence of the elliptical paralysis, which, of course, increased the area of the breathing 
space. Another element of the case, also due to his chronic laryngitis, which thus 
became eminently a conservative condition, was a certain amount of thickening of 
the inter- arytenoid commissure, which served to hold the arytenoid cartilages apart 
during inspiration. The result'of these two conditions was to render the voice some- 
what weak, but, on the other hand, they so widened the riraa glottidis that quiet 
respiration was carried on with comparative ease. 

Case V. — Kiegel,' in 1873, reported the case of a boy five years of age, who, dur- 
ing his second year, had an attack of quinsy, from which he recovered without any 
bad results. In his third year he began to suffer with inspiratory dyspnoea, the voice 
remaining unimpaired. At the end of his fifth year he was brought under Riegel's 
notice in a weak and emaciated condition, with enlarged and suppurating lymphatic 
glands. Laryngoscopic examination revealed the characteristic appearance of bilat- 
eral paralysis of the abductor muscles. Therapeutic measures were powerless to 
relieve, and the patient died from a subsequent attack of measles with pneumonia. 
An autopsy in this case revealed both recurrent laryngeal nerves compressed by dense 
connective tissue, and the nerve-fibres in a state of fatty degeneration and atrophy. 
The pneumogastric and sympathetic nerves were normal. The crico-arytenoidei 
postici muscles were in a state of atrophy, while the other muscles of the larynx 
were normal. 



Ziemssen, from Berlin, klin. Wochenschrift, Xos. 20, 21, 1872; No. 7, 1873. 

23 



354 NEUROSES OF THE LARYNX. 

Case VI.— Riegel,' in December, 1874, reported the case of a man, fifty-eight 
years of age, a guide by occupation, who was admitted to the hospital in Cologne, 
giving a history of attaclis of dyspnoea, cough, and expectoration, of a month's stand- 
ing. He had the characteristic inspiratory dyspnoea, and breathing was very labored. 
Laryngoscopic examination revealed bilateral paralysis of the abductors, with the 
mucous membrane in a state of catarrhal inflammation, with ulceration. Tracheot- 
omy was performed the day following his admission. The man had also serious pul- 
monary disease, which was undoubtedly aggravated by the introduction of the tube. 
Death occurred one week after the operation, from the lung disease. On postmor- 
tem examination, the posterior crico-arytenoid muscles were found to be in a state 
of complete atrophy, scarcely a trace of muscular tissue being found. All the other 
laryngeal muscles were normal, as were the recurrent and pneumogastric nerves. 

Case VII. — Penzoldt - reports the case of a woman, sixty-one years of age, who 
came under his observation, with a history of former .syphilis and cerebral apo- 
plexy. She presented extensive cicatrices in the pharynx and soft palate. She gave 
the clinical history of inspiratory dyspnoea. Laryngoscopic examination revealed 
the cords motionless in the median line, with a moderate degree of catarrhal inflam- 
mation of the lining membrane of the larynx. Tracheotomy was performed to relieve 
dyspnoea, but death ensued in a few days, the result of an existing pulmonary dis 
ease. Post-mortem examination revealed a degeneration of the crico-arytenoidei 
postici muscles, while the other laryngeal muscles were normal. There was a mod- 
erate degree of degeneration of the recurrent nerves, extending to the pneumogastric 
and spinal accessory, with moderate sclerosis of the medulla oblongata. 

Case VIII. — Feith ^ reports the case of a woman, sixty-eight years of age, who 
was seized with an attack of facial erysipelas, which was followed by a double 
pneumonia, both of which underwent fair resolution ; but at the end of the sixth 
week after the attack of erysipelas, and two weeks after the resolution of the pneu- 
monia, she was suddenly seized with paroxysms of inspiratory dyspnoea, which, 
gradually increasing, became of an extremely alarming character, the voice not being 
impaired. The laryngoscope showed paralysis of abduction, the laryngeal cavity 
being otherwise normal. At the end of four or five days after the first onset of the 
dyspnoea, tracheotomy became necessary. Electrical and other treatment failed to 
accomplish any good result, and the patient continued to wear the tube. 

Case IX. — H. von Ziemssen* reports the case of a man, aged twenty-six, who 
had always enjoyed good health, and who on New Year's day, of 1871, was seized 
with dyspnoea of an inspiratory character, followed by recurring exacerbations. 
These recurred at first only at night, but, gradually increasing, appeared during the 
day, being brought on by any unusual effort. The symptoms growing worse, on 
August 11, 1871, seven months and a half after the beginning of his trouble, he was 
compelled to seek hospital treatment, at which time the laryngoscope showed the 
motionless condition of the vocal cords, with moderate injection of the mucous mem- 
brane lining the larynx. The voice was not much impaired ; no traces of syphilis 
were found. He was placed under treatment by electricity, which was continued 
for six weeks, when he was discharged cured. 

Case X. — Mackenzie ^ reports the case of an American gentleman, aged sixty- 

1 Ziemssen, from Volkmann's Sammlung kJin. Vortrage, No. 95. 

2 Ziemssen's Cyclopasdia, vol. vii. , p. 962. 

3 Ibid. 

^Ibid., vol. vii., p. 963. 

' Mackenzie, On the Laryngoscope, p. 217. 



BILATERAL PAEALYSIS OF THE ABDUCTOES. 355 

one, a lawyer, who for thirty years had complained of a weak voice. For eighteen 
years he had been subject to cramps in the throat, and for eight years had suffered 
from dyspnoaa, which had gradually but slowly increased. The examination revealed 
paralysis of the abductor muscles. Tracheobomy became imperative, and the gen- 
tleman is still wearing the tube, as I am informed by Dr. Roe, of Rochester, under 
whose observation he is at present. 

Case XI. — Rehn ' reports the case of a boy of thirteen, convalescing from an 
attack of typhoid fever, who was attacked fourteen days af ber the cessation of the 
fever with shortness of breath, which was increased by the slightest exertion. 
Laryngoscopy showed complete paralysis of abduction of the cords. Tracheotomy 
was performed, the tube being worn fifteen weeks, and the patient kept on a sup- 
porting and general tonic treatment. At the end of this time the tube was removed, 
the cure being satisfactory. 

Case XII. — Dr. Lefferts'^ reports the case of a robust Irish woman, about forty 
years of age, who came to him on the 8th of May, 1876, with a history of what was 
probably an attack of mucous patches in the mouth, five years before, with a recur- 
rence of specific disease in the form of extensive ulceration in the fauces in Decem- 
ber, 1875. A few days previous to her visit, she began to suffer with difiiculty in 
breathing, which was at first but slight in character, and only noticeable after an 
unusual exertion and at night ; gradually it began to show itself during the day also. 
The voice was unaffected. There was the characteristic inspiratory dyspnoea. 
Laryngoscopic examination showed complete paralysis of the abductors, with a 
slightly reddened condition of the mucous membrane. She was immediately put on 
lull and increasing doses of iodide of potassium, with the most excellent results, as 
aU evidences of the disease had disappeared at the end of six weeks. 

Case XIII. — Dr. Lefferts^ reports a second case, that of a woman thirty-five 
years of age, who gave a very clear history of syphilis. In October, 1877, she con- 
tracted a severe cold, soon followed by difficulty of breathing, with hoarseness. 
This increased rapidly until the dyspnoea became distressing and constant. This 
passed away, however, under treatment, but in April, 1878, as the result of a fresh 
exposure, a progressive dyspnoea again set in, which did not yield to treatment. 
During the second week she had paroxysmal attacks of dyspnoea both day and night. 
On June 1, 1878, Dr. Lefferts saw her, after a very grave and alarming attack of 
dyspnoea. When he first saw her the subjective symptoms were not prominent, but 
laryngoscopic examination showed complete paralysis of the abductors of the vocal 
cords, with the whole mucous membrane lining the larynx in a state of hyperaamia. 
She was immediately placed under the influence of iodide of potassium with mer- 
cury, with most excellent results. The subjective symptoms disappeared, and a 
satisfactory condition of mobility of the cords followed. 

Case XIV. — Dr. Cohen •* reports the case of a gentleman, forty-six years of age, 
whose only vice had been the excessive use of tobacco, who consulted him, giving 
the history of cough, dyspnoea, and occasional attacks of spasm of the glottis extend- 
ing over two years. The spasm was induced always by the irritation of the external 
auditory meatus. Laryngoscopic examination showed paralysis of the left abductor 
muscle. The spasms recurred with sush violence that tracheotomy became neces- 
sary. Very soon after the operation the muscles of the right side also became para- 



' Von Zicmssen's Cyclopedia, vol. vii., p. 905. 
- New York Medical Jouraal, December, 1878. 
3 Ibid. 
■• Diseases of the Throat, 2d cil., p. G.j-4. 



356 NEUROSES OF THE LARYNX. 

lyzed, and the glottis remained so entirely closed that Dr. Cohen suspected spasm of 
the crico-arytenoideus lateralis and arytenoideus muscles. The patient continues to 
wear the tube, all treatment having proved useless. 

Case XV. — Burow' reports the case of a man, aged sixty-two. who came to his 
clinic January 5, 1879, with a history of dyspnoja of four months. The inspiration 
was very noisy ; the voice was normal. Laryngoscopy revealed the usual picture of 
paralysis of the abductors. January 14th the trachea was opened, but the patient 
died from pulmonary disease two weeks later. The autopsy revealed a hyperplastic 
mass pressing on both recurrent laryngeal nerves, with atrophy and fatty degenera- 
tion of the two abductor muscles. 

Case XVI. — Meschede, of Konigsberg,^ reports a case as follows : A girl, aged 
nineteen, was brought to him by her mother, with the history of complete aphonia of 
two months' standing. There was some bloody expectoration, but no signs of lung 
disease. The prominent symptoms were those of marked inspiratory dyspnoea, with 
noisy inspiration at all times, but extreme on slight exertion. Menstruation had 
ceased for several months. The laryngoscopic examination wa? made with difficulty, 
but revealed the usual appearance of paralysis of the abductor muscles of the cords. 
There was a suspicion of hysteria, but this diagnosis was abandoned, on the ground 
that the cords could not be maintained in a state of approximation so long a time. 
The false color in the picture here of course was the aphonia, but it was interesting 
to note that, under the threat of using the actual cautery, she recovered the use of 
the voice. The dyspnoea pei-sisted, however, and finally yielded only to the subcuta- 
neous injection of strychnia. After four months' treatment she was entirely cured. 

Case XVIL — Among Dr. Warren's surgical cases ^ I find the following: A child, 
aged three, was brought to the hospital, July 17, 1876, with the following history : 
Eight months ago he had a severe cough, followed in three weeks by enlargement- and 
finally suppuration of the cervical glands. At this time the child, though not well, 
was not really sick. About the middle of January the voice became husky, and the 
child began to suffer from inspiratory dyspnoea. The symptoms were alarming for a 
time, but finally an improvement set in, and was progressing fairly, until a few weeks 
before the child was brought to the hospital, they recurred in an alarming degree, the 
prominent features being marked inspiratory dyspnoea, with noisy inspiration and 
recurring paroxysms of a serious character. Dr. Knight now saw the child, and made 
the diagnosis of paralysis of the abductors of the larynx. On July 21, 1875, trache- 
otomy was performed. Treatment for the relief of the paralysis was of no avail, and I 
learn from Dr. Knight that the child, now eight years old, still wears the canula. 

Case XVIII. — Dr. John S. Blake ^ reports the following : A girl of six years was 
brought to him October 25, 187(), with the following history. Six months before she 
had scarlet fever and diphtheria of unusual severity, but had made a perfect recov- 
ery. A week before he saw her she had a croupy cough, with noisy breathing at 
night. The voice was unaffected. A yellowish exudation was found on the tonsils. 
The symptoms becoming worse, Dr. Knight was called to see her, and on laryngo- 
scopic examination discovered the characteristic appearances of paralysis of the ab- 
ductors, and advised tracheotomy. This was deferred for a few days, but was 
finally resorted to when the patient was in extremis. The respiration was estab- 
lished, and treatment at the same time was instituted for the deposit, which was 

' Berliner klin. Wochenschrift, Nos. 33, 34, 1879. 
nUd., No. 17, 1878. 

3 Boston Med. and Surg. Jour., August 31, 1876. 
^Ibid., August 33, 1877. 



BILATEEAL PAEALTSIS OF THE ABDUCTOES. 357 

probably diphtheritic. At the end of a week the tube was removed and recovery 
was complete. 

Case XIX. — Dr. Knight ' reports the following' case : A man aged thirty-six, a 
ship -carpenter by trade, was referred to him by L>r. Ingalls in September, 1868, with 
the following history. In 1854 he had had n primary sore, followed in six months by 
an eruption on the skin, and in the years following, up to the time Dr. Knight saw 
him, he had repeated attacks of rheumatism, skin eruptions, and sore-throat. In 
December, 1867, he began to have sore-throat with hoarseness, and to fail in strength. 
A laryngoscopic examination at the time revealed the chronic laryngitis of syphilis. 
After treatment for two weeks, he was improving, when he disappeared, and was not 
again seen until August, 1869, when he i^resented himself with a tube in the trachea, 
which had been inserted in March, seven months after he had disappeared, for a 
progressive dyspnoea. An examination showed paralysis of the abductors. He con- 
tinued to wear the tube. 

Case XX. — Dr. Glynn - reports the case of a man, aged thirty-sis, who was ad- 
mitted to the Eoyal Infirmary iu Liverpool, January 16, 1877, suffering from inspira- 
tory dyspnoea, etc. , the result of an exposure to cold three weeks previously. Exam- 
ination showed acute inflammation of the membrane of the larynx and fauces, with 
paralysis of the abductor muscles. Local and internal medication was of no avail, and 
tracheotomy became necessary, January 19th. The local application of electricity 
was now used, and in two months the tube was removed. As late as June 2Cth there 
had been no recurrence of the trouble. 

Case XXI.— Dr. A. H. Smith -^ reports the following case : F. C, aged fifty, a 
messenger, consulted Dr. Smith, on September 8, 1877, suffering from an urgent 
dyspnoea, which had been coming on two years, but had grown much worse during 
the previous fortnight. The voice was husky, but otherwise normal. An examina- 
tion showed the cords motionless in the median line, with a moderate hypera?mia of 
the mucous lining of the larj'nx. The patient gave a clear history of syphilis, con- 
tracted ten years before, followed by secondary lesions. Tracheotomy was performed 
the following day, and the patient was put on the use of full doses of iodide of potas- 
sium, and localized faradization was used. The treatment resulted in complete cure 
of the paralysis at the end of four weeks. The tube causing considerable irritation, 
it was removed. Sis weeks later the disease returned suddenly, and before the 
operation could be rei^eated the patient died. 

Case XXII. — Dr. Knight ■• reports the case of a lady, aged sisty, who, after a slow 
convalescence from typhoid fever, developed a cough with hoarseness, which finally 
resulted in dyspnoea of a spasmodic character. An examination revealed the usual 
appearance of bilateral paralysis of the abductor muscles. The dyspnoea becoming 
severe in character, tracheotomy was performed. Treatment was of no avail, and the 
tube was worn permanently. 

Case XXIII. — Dr. Robinson,^ of New York, reports the following : A railway de- 
tective came under his care, with a clear history of syphilis of seventeen years stand- 
ing. In addition to some general nervous symptoms, he began to have marked 
dyspnrjea two j'ears befoi'C, characterized by exacerbations recurring with more or 
less frequency. Examination of the larynx showed paralysis of the abductors. He 



Boston Med. and Surg. Jour., September 30, 1869. 
'Lancet, September 1, 1877. 
'Am. Jour, of the Med Sci. , January, 1878. 
' Bo.ston Med. and Surg. Jour., February 25, 1809. 
• Am. Jour, of the Med. Sci., April, 1878. 



358 NEUROSES OF THE LAEYNX. 

was put under specific treatment with but little avail ; but, the symptoms not being 
sufficiently urgent, tracheotomy was not done, and he was subsequently lost sight of. 

Case XXIV. — Juraz ' reports the following case : The patient, during convales- 
cence from typhoid fever, which set in May 1. 1877, was seized with dyspnoea of the 
peculiar inspiratory character, the voice not being impaired. This increased, and on 
June 28, 1877, two days after the dyspnoea set in, tracheotomy became imperative. 
June 20, 1878, a year afterward, still wearing the canula, he went to Czerny, who for 
the first time made application of electricity, and found good reaction in all the la- 
ryngeal muscles, except the abductors, but in these only a very feeble reaction. 
Several months of treatment, however, failed to give any permanent results. 

Case XXV. — Whipham ^ reports the case of a cabman, aged twenty-six, who came 
to the out-patient department of St. George's Hospital, with the history of syphilis 
beginning three yeai's before. For three months he had had sore-throat, with some 
dyspncea and inspiratory stridor. Examination revealed a laryngitis, with almost 
complete bilateral paralysis of the abductors. His laryngitis was cured, but the 
paralysis remained much the same, and, under treatment for sixteen months, there 
was no improvement. Tracheotomy was not performed. 

Case XXVI. — Dr. Weber ' reports the following case : A man, aged thirty-seven, 
had been somewhat hoarse for two years, and for four months had shown decided 
evidence of phthisis. There was no history of syphilis. Sudden and marked dyspnoea 
set in, of the peculiar inspiratory character, which at the end of one week demanded 
tracheotomy. At the end of a month there was no improvement in the paralysis. 
There is no later report. 

Case XXVII. — Hughlings Jackson'* reports the case of a man, aged thirty -five, 
who came under his care December 5, 18(54, with the history of having had syphilis 
several years before. For four years he had had more or less inspiratory dyspnoea. 
December 23d tracheotomy was performed. The following night he died from suffo- 
cation, the tube having become occluded with mucus. The autopsy revealed com- 
plete atrophy of the abductor muscles. The pneumogastric and recurrent nerves 
were perfectly healthy. 

Case XXVIII. — Hays ^ reports the case of a man aged thirty-one, who came under 
his care August 4, 1879, with the history of dyspnoea of inspiratory character of two 
months' standing. He had had a chancre eight years before. Examination revealed 
paralysis of the abductors. Under treatment for two mouths and a half by iodide of 
potassium and electricity he was cured. 

Case XXIX. — Mackenzie^ reports as follows : J. H., aged forty, was admitted to 
hospital in January, 1878. Twenty-one months previously he had caught cold, which 
resulted in a severe dyspnoea, which had increased slowly iintil he applied for admis- 
sion to hospital, when the symptoms were so urgent that tracheotomy was performed 
immediately. The i^atieut died two months afterward. An examination previously 
had revealed paralysis of the abductor muscles. The autopsy disclosed an abscess in 
the posterior wall of the cricoid cartilage, which had destroyed the abductor muscles. 

Case XXX. — Mackenzie ' reports the following : C. E., aged thirty-four, a gym- 

' Deutsche med. Wochenschrift, April 5, 1879. 

■^ St. George's Hosp. Reports, 1878. 

3 Phila. Med. Times, June 19, 1880. 

■* Med. Times and Gazette, December 15, 1SG6. 

5 Dublin Jour, of Med. Sci., January, 1880. 

^ Diseases of the Throat and Nose, vol. i. , p. 443. 

'• Ibid., vol, 1., p. 443. 



BILATEEAL PARALYSIS OF THE ABDUCTOES. 359 

nast, was admitted to hospital November 22, 1876, with the history of a chancre 
eighteen years previously. For eight months he had been subject to recurrent at- 
tacks of dyspnoea. He was veiy short of breath, but the voice was normal. Trache- 
otomy was performed, but the patient died eight days afterward from pneumonia. An 
autopsy revealed degeneration of the abductor muscles. The nerves were healthy. 
The brain was not examined. 

These cases comprise but a part of tlie number wliicli have 
been reported ; but they are mainly selected as giving informa- 
tion as to the cause, clinical history, and pathological changes 
which belong to the affection. Many of the reported cases 
have been rejected as incomplete and adding nothing to our 
information of the disease. Such as Gerhardt's,' Duranty's," 
Semon's,' Smith's,* Mackenzie's," Heinze's," Klemm's,' and 
Gruttmann and FraukeF s.' 

In glancing over the above-detailed cases, we find the 
causes of the paralysis as follows : 

Cases. 

Syphilis 12 

Convalescence from typhoid fever 8 

Erysipelas 1 

Chronic nicotine poisoning 1 

Localized inflammation 2 

Scrofula' 1 

Diphtheria 1 

Epithelioma 1 

Phthisis 2 

Hysteria 1 

No causes recorded in 5 

We thus find that S3'philis is responsible for forty j)er cent. 
of all the cases. Of these twelve patients, eight had tracheoto- 
my performed, and were compelled to wear the tube during 
life, two of them, however, dying within a few days after the 
operation from intercurrent causes. Three of the four patients 
in whom the trachea was not opened were cured by internal 

' Ziemssen's Cyclopagdia, vol. vii., p. 959. 
" Ibid. , p. 965. 
•■ Lancet, April 20, 1878. 
•* Brit. Med. Journal, July i:i, 1878. 

"> Cases 4, 5, 6, and 8, Diseases of the Throat and Nose, vol. i., p. 444 et seq. 
^ Archiv flir Heilkunde, xvi., 1875. 
'' Ibid., 187G, p. 516. 
I * Berliner klin. Wochenschrift, No. 10, 1878. 



360 LEUKOSES OF THE LAEY^^X. 

medication. The fourth, AYhipham's, seems not to have de- 
veloped any very alarming symptoms, although under observa- 
tion nearly two years. In the three cases cured by the admin- 
istration of medicine the disease had existed respectively, a few 
days, six weeks, and two months. In the six patients who 
wore the trachea tube permanently, leaving out of considera- 
tion the two that died, we find that the disease had existed in 
two cases two years, in three cases one year, and in one case 
six months. 

The deduction from this is obvious. Prominent among tlie 
causes of the disease stands the syj)hilitic poison, which acts 
by producing some degenerative change that, if not arrested 
promptly, will go on to the complete destruction of the func- 
tional activity of the organ involved, beyond the possibility of 
its restoration. On the other hand, if the disease is recognized 
sufficiently early, we may entertain fair hope of cure hy inter- 
nal medication. In one case erysipelas w^as apiDarently the 
cause. In this case, although the operation was performed 
early, the tube was worn during life. 

The case of Meschede has been introduced as afi'ording 
some iDoints of interest, but it is scarcely to be accepted as a 
genuine case of the disease under consideration. I have also 
added my own case of epithelioma and Weber's case of laryn- 
geal phthisis, as illustrating the manner in which a localized 
morbid process may extend to the muscular structures to dis- 
integrate and paralyze them, thus becoming another cause of 
this disease. 

We also see that, in addition to syphilis, any blood poison 
ma}^ produce this affection ; but there lies this difference : the 
slowly acting, chronic blood poisons — syphilis, scrofula,, nico- 
tine poisoning, etc. — have, in the cases cited, led to irreparable 
morbid changes, which have resulted in a jDaralysis not amena- 
ble to treatment ; while the acute blood poisons, such as those 
of typhoid fever, dii3litheria, etc., have resulted in a temporary 
paralysis, which, though of very aggravated character, and re- 
quiring tracheotomy, has yielded to treatment, and resulted in 
complete cure. 

As regards the true pathology of the disease, it seems to me 
that the clinical histories of the cases given shed more light on 
it than the eight autopsies which were made. In one of these 
a tumor was found pressing on both recurrent laryngeal nerves, 



BILATEEAL PARALYSIS OF THE ABDUCTORS. 361 

with atrophy of the abductor muscles ; in one, cicatricial bands 
pressing on each recurrent nerve, with atrophy of the abduc- 
tors ; in one case, degeneration of the recurrent nerve, also of the 
pneumogastric and the spinal accessory, with sclerosis of the 
medulla ; but, in the five remaining cases, there was found sim- 
ply atrophy of the muscles, while the nerves were unimpaired. 

It will be noticed that, in all the cases examined post-mor- 
tem, the muscular structures were destroyed by degenerative 
changes, while the nerves supplying them were perfectly 
healthy in five cases and diseased in three. Furthermore, it 
will be observed that the muscular atrophy was confined to 
the abductor muscles alone, while the other muscles of the 
larynx, although supplied by the ver}^ nerves which were in a 
diseased state in three cases, and healthy in five, retained their 
normal integrity. 

The question arises, does the seat of the original morbid 
changes which produce the paralysis lie in the nerve-trunks ? 
I do not see how this view of the subject can be entertained 
for a moment. Any disease of the recurrent laryngeal nerve, 
which has progressed so far as to destroy its conductivity, must 
destroy and paralyze all the muscles which it supplies. In two 
of the cases narrated there was found pressure on both nerves, 
and yet the abductor muscles alone were atrophied, wliile the 
others were healthy ; moreover, during life, in these cases, the 
other muscles were in a state of healthy functional activity. 

As was said at the opening of the chapter, the essential 
gravity of the disease lies in the integrity of the crico-arj^te- 
noidei laterales muscles — the opposing muscles to the abduc- 
tors ; for, if these muscles were also paralyzed, as the}^ must 
necessarily be, were the conductivity of the nerve destroyed 
b}'' disease, no dyspnoea would exist ; the glottis would fall 
into the i^osition known as the cadaveric position, which, as 
we know, is sufficiently wide to allow of free and unimpeded 
respiration. This is illustrated by those rare cases, one or two 
of which have been reported, in wliicli there was pressure on 
both recurrent laryngeal nerves, and in wliicli the prominent 
symptom was complete ai)honia, witliout dyspnea. The fact 
that the voice is unimpaired, as a rule, in paralj^sis of tlie ab- 
ductors is sufficient evidence that the other muscles of the 
larynx are in a healthy state. As to the suggestion I have 
seen made, that the disease is due to pressure on the recurrent 



362 NEUROSES OF THE LARYNX. 

nerves, and that this pressure may so far discriminate between 
the nerve-fibres as to destroy the conductivity of those fibres 
alone which are distributed to the abductor muscles, it seems 
to me that the assertion is utterly untenable. That this might 
happen on one side alone, and that a tumor pressing npon the 
trunk of the recurrent nerve might so far select its points of 
pressure as to paralj^ze the abductor muscle of that side, is 
among the possibilities ; that this should happen on both sides, 
and to both recurrent nerve-trunks, would be one of the rarest 
of coincidences ; that it should happen in a large series of 
cases is simply beyond the pale of possibility. 

I think, then, that we must look still further for the morbid 
condition which produces the disease, and not in the nerve- 
trunks which supply the muscles of the larynx. As suggested 
in the early portion of the paper, reasoning from analogy, con- 
sidering the peculiar character of the respiratory movements 
of the larynx, in that they are purely involuntary and also 
reflex ; that the opening of the glottis, constituting the respir- 
atory movement, is an independent action separated from all 
the other movements which take place in the larjaix as the re- 
sult of muscular contractions ; it is fair to conclude that this 
function is presided over by an independent ganglionic nerve- 
centre, and that the disease in question consists in some degen- 
erative change taking place in this portion of the brain ; that 
it occurs most frequently as the result of syphilis, but that it 
may also occur under the influence of any of the blood poi- 
sons ; and that these changes become permanent and incurable 
unless arrested very early in the career of the disease. 

In three of the autopsies made there was nerve-lesion ; in 
all, muscular atrophy. For reasons already given, the nerve- 
lesion could not paralyze the abductor muscles without para- 
lyzing the opponent musdles also. We must, therefore, con- 
clude that these nerve-lesions are due to the same cause which, 
acting on the nerve-centre which presides over the respiratory 
movements of the larynx, has led to degeneration, and that 
they have occurred subsequently to it ; or that the nerve- 
lesions, occurring first, have reacted upon the nerve-centre, 
and set in play forces which have acted to produce degenera- 
tive changes there ; whichever of these hypotheses be the true 
one, the conclusion is unavoidable that the lesion of the nerve- 
trunk cannot account for the symptoms of the disease, and 



BILATEEAL PAEALTSIS OF THE ABDUCTOES. 363 

that the central origin of the affection shonld be accepted as 
the true explanation. Additional evidence in favor of the cen- 
tral origin of the disease is found in the obscure brain-symp- 
toms which attended a number of the cases reported, which 
would seem to point to the existence of some central lesion 
involving other parts than those which preside over this respira- 
tory function of the glottis, 

Mackenzie, in his earlier work,' writing of this affection, 
makes the assertion that it is due to some central lesion in the 
brain, and he is the only writer that I find who ventures to 
assign any cause for the disease. In his later work," however, 
he seems to have abandoned this theory, and leans rather to 
the view that the source of the affection is in the muscles them- 
selves. This is undoubtedly true in those cases in which we 
find localized infiltration from neighboring tubercular or syphil- 
itic disease ; but in those cases cited, in which, as the result of 
blood-poisoning, the affection advanced slowly but surely to 
an untoward result, it would seem that there must be some 
further explanation than the localized morbid process. 

If the disease were a local one in the muscles themselves, 
we should certainly notice in some cases that the paralysis 
invaded one muscle to its destruction, while its fellow remained 
intact. This, however, rarely, if ever, happens, for the clinical 
history of the recurrent sj)asmodic dyspnoea would show that 
both muscles were involved from the outset. And certainly, 
when they come under inspection, it is an extremely rare event 
to notice any difference in the motility of the two sides. In- 
deed, I do not think this has ever been observed in a case which 
was a true bilateral paralysis of the abductors, and not a 
secondary infiltration of the muscles. 

Treatment. — x4.s regards the treatment of these cases, what 
has been said in the course of the cliapter is sufficient to make 
the prominent indications plain. Those cases in which the 
disease is recognized early in its course, and which are trace- 
able to a specific taint, can be cured by medication. Those 
cases in which the symjitoms have persisted for six months or 
more will eventually demand tracheotomy by the exigencies of 
the dyspnoea, and the tube will need to be worn during life. 

I think that another and most important conclusion may 

' Hoarseness and Loss of Voice. Philadelphia, 180!). 
'Diseases of the Throat and Nose, vol. i., London, 1880. 



364 NEUROSES OF THE LAEYNX. 

be drawn. If the traclieotomy lias been deferred too long, the 
weary and struggling muscle will have so far lost its vitality 
that an}^ hope of its recovering its contractility will have been 
destroyed ; whereas, had the disease been recognized early and 
the trachea opened, thereb}^ setting at rest the respiratory 
movements in the larynx, there would be a much better hope 
that its integrity might be restored. By this, of course, I do 
uot mean absolute and entire rest, for in such a case I should 
consider it of the utmost importance that the larynx should 
be subjected to dail}^ use, of a moderate character, in talking 
and breathing occasionally with the mouth of the tube closed. 

In a case, therefore, in w^hich we recognize the condition 
early, and in which improvement is not accomplished as the 
result of treatment, I think the advisability of an early tra- 
cheotomy cannot be questioned. This, I think, is shown in 
every case which I have related in which the tube became a 
permanent need, and also in every case in which the operation 
was done early in the disease, as, in these latter cases, with one 
exception, the result was a permanent cure, while in the former 
cases the operation was done only after the muscles had under- 
gone complete atrophy. The operation is a very simple one, 
and unattended with any immediate danger. The untoward 
sequelae which are liable to occur may be prevented by proper 
precautions. A delay is constantly endangering the integrity 
of the muscle, and too great a delay will surely render the 
operation imperative, but then only to be followed by the terri- 
ble necessity of wearing a trachea tube during life. 

Among the cases detailed, I have given one in which the 
paralysis was due to epithelioma, and another in which it was 
an accompaniment of larj^ngeal phthisis. Of course, these two 
cases are not to be classified under the same category with 
those in which the j)aralysis is j)rimary. The cases are given 
as illustrative of the manner in which the disease may occur 
as a secondary affection, and as a complication of local mani- 
festations of cancer, phthisis, or syphilis in the larynx. 

In connection with the indications for treatment already 
given, the use of the Faradic current should be resorted to 
as materially aiding to preserve the integrity of the muscular 
structures and restoring their contractility. The special methods 
by which this may be accomplished have already been suffi- 
ciently described in the previous chapter. 



CHAPTER XXII. 

TUMOES OF THE LAEYNX. 

The existence of tumors or polypi in the larynx was recog- 
nized as far back as the middle of the eighteenth century, and 
operations were resorted to for their removal. The diagnosis in 
these cases was based on the subjective symptoms and digital 
exj)loration. In occasional cases in which the growth projected 
above the laryngeal cavity, it was recognized by direct inspec- 
tion. The operations for their removal consisted in opening 
the larynx from without ; although in one or two cases their 
removal was attempted through the natural passages. Since 
Czermak, in 1859, lirst recognized a laryngeal growth by means 
of the laryngoscopic mirror, a very large number of these 
tumors have been observed, and successfully removed by 
means of some of tjie ingenious instruments which have been 
especially devised for the purpose. 

The symptoms which point to the existence of a laryngeal 
growth are in the main of a purely mechanical character, and 
depend on the size and location of the neoplasm. If the attach- 
ment be to the vocal cords the voice is either lost by the inter- 
ference with the closure of the glottis, or impaired by the inter- 
ference with the vibration of the cords. If the attacliment is 
to the commissure of the arytenoids, their closure is liable to 
be thereby prevented and the voice lost. 

Dyspnoea is entirely dependent on the size and location of 
th^ growth. If the tumor is attached to the epiglottis it may 
cause painful or difficult deglutition. The cause of a laryngeal 
growth is probably, in most cases, a clironic catarrli ; aside 
from this we are unable to recognize any direct cause. They 
occur in singers, i^ublic speakers, and those accustomed to make 
special use of the voice, more frequently tlian in otliers. Males 
are more liable to tliese occurrences than females, ])roI)ably 
from the fact that they sulfer more frequently from catarrhal 



366 TUMORS OF THE LARYNX. 

inflammations of the upper air-passages. They are most fre- 
quently met witli in middle life, though they occur at every age, 
and are by no means infrequent in young children. Their at- 
tachment, in by far the largest proportion of instances, is to the 
vocal cords, though no region of the larj'nx is exempt. Laryn- 
geal growths may be classified under the head of benign, serai- 
malignant, and malignant tumors. 

Bexign Tumors. 

The benign tumors met with in the larynx are, papillo- 
mata, jihromata, cystic tumors, myxo'inata, lipomata, and an- 
giomata. 

Papillomata or warty growths are analagous to the ordi- 
nary wart which occurs on the finger, and are by far the most 
common of tumors, comprising nearly three-fourths of all 
laryngeal growths. In structure they resemble the normal pa- 
pillae, from which they receive their name. They have their 
origin in the connective tissue of the subepithelial laj^er of the 
mucous membrane wiiich forms the basis of the growth, and 
are covered by a number of layers of epithelium. Occasionally 
blood-vessels and nerves are found composing a part of the 
mass. Their growth is somewhat slow% but th^j may attain a 
considerable size, to the extent often of producing no little ob- 
struction to respiration. The}^ are generally sessile in charac- 
ter, of a soft and friable consistence, and liable to be somewhat 
vascular. On inspection they present a grayish color with a 
somewhat irregular outline, having something of the appear- 
ance of the ordinary wart on the finger. In other cases they 
have a decidedly red color as the result of excessive vascular- 
ity. Their surface is usually studded with minute pointed pro- 
jections or rounded masses, of an appearance somewhat like 
that of a cauliflower excrescence. Their most frequent site is 
the vocal cords, especially near the anterior extremity. Occa- 
sionally they arise from the comiuissure of the arytenoids, less 
frequentl}^ from the false cords or epiglottis. After removal 
they show a tendency to recur, wdien their development is far 
more rapid than before. Fig. 140 shows a papilloma attached 
to the left vocal cord. This cut very well illustrates the gross 
appearances of these tumors, and also the average size in which 
they occur in the very large majority of cases. 



BENIGN- TUMOES. 367 

Fig. 141 illustrates a case in wliicli the growth has attained 
a very unusual size. 

Fibromata. — This form of growth is found in the larynx 
next in frequency to that of the papilloma. According to Mac- 
kenzie, about ten per cent, of laryngeal growths are fibroma- 
tous. In structure they consist of bundles of dense fibrous tis- 
sue interlacing in every direction. They contain but very few 



Fig. 140.— Papilloma attached to the left vocal cord. (Mackenzie.) 
Fig. 141.— Multiple papilloma of umisual size. (Mackenzie.) 



blood-vessels, and, as a rule, are of a hard, firm consistency. 
They have their origin in the submucous connective tissue. A 
fibrous tumor may present itself as a single rounded mass (see 
Fig. 142), or as a group of small tumors (see Fig. 148). In outline 
it is generally rounded and is covered with mucous membrane 
of a dirty white or red color. Its growth is extremely slow 
and it rarely attains to any great size. After removal there is 




Fig. 14i>. Fig- 1-13. 

Fio. 142.— Single flbromu. (Mackenzie). 
Fig. 143.— Multiple flbroma. (Mackenzie.) 

no tendenc}' to relapse. As a rule the growth is pedunculated, 
though occasionally it may be sessile. Sometimes the pedicle, 
especially if attached to one of the vocal cords, may become 
elongated in such a manner as to admit of considerable free- 
dom of motion in the tumor. Their starting-point, in the ma- 
jority of cases, is in the vocal cords. Occasionally they are 
met with attached to the false cords or epiglottis. 

Cystic iu??iors.— These are among the rarer tumors of tlie 



368 TUMOES OF THE LAEYNX. 

larynx and consist of small collections of fluid or semi-fluid 
material contained within a C3^st-wall or capsule. In the la- 
rynx their source is in a distended follicle, jDrobably, whose 
excretory duct having become closed, the normal secretion in- 
creases and distending the follicular wall, develops gradually 
into the cystic tumor. They grow very slowly, and rarely at- 
tain any great size, and when punctured and thoroughly 
emj)tied of their contents show little tendency to recurrence. 



Fig. 144.— Cystic tumor attached to the epiglottis. (Mackenzie.) 
Fig. 145.— Angioma springing from the hycid fossa. (Mackenzie.) 

Fig. 144 illustrates a case reported by Mackenzie, in which the 
cyst springs from the epiglottis. 

Myxomata. — These are tumors composed mainly of mucous 
tissue, and have been met with in the larj^nx but twice, as far 
as I know ; one case having been reported b}' Yon Bruns and 
another by Mackenzie. 

Lipomata^ or ordinary fatty tumors, have been met with 
but once, the case being reported by Yon Bruns. 

Angioinata. — These tumors consist of enlarged and tortuous 
blood-vessels, held together by a small amount of loose connec- 
tive tissue. In character they are analogous to the ordinary 
naevi of the skin. They have a bluish or purplish color, with 
something of the appearance of a blackberry. They are ex- 
tremely rare. Fig. 145 illustrates a case reported by Macken- 
zie in which the mass springs from the hyoid fossa. 



Chokditis Tuberosa. 

This is an afi:ection of the larynx, which is sometimes de- 
scribed under the head of neoplasms. It consists in the devel- 
opment, on one or both of the vocal cords, of a small, rounded 
nodule or tuberosity. 

Tuerck, I believe, first described this affection under the 



CHORDITIS TtJBEEOSA. 369 

name of chorditis tuberosa, wliicli would seem a more appro- 
priate name than tliat of a tumor. There is developed on the 
vocal cord, generally midway between the vocal process and 
its anterior insertion, a small, rounded projection, sessile in 
character and standing out from the free border of the cord, 
showing itself distinctly in profile on a laryngoscopic exami- 
nation. It is of a grayish color, with a moderate amount of 
noticeable injection of the blood-vessels surrounding it. It de- 
velops very slowly, rarely attaining a size larger than a pin- 
head, and when developed, remains stationary as to size. 
There is usually seen on the opposite cord, at the point 
where the tuberosity impinges upon it in phonation, a corre- 
sponding depression, though in one case which came under 
my observation there was developed a similar condition on the 
cord of the opposite side, the tuberosities meeting in the median 
line during attempted phonation. 

The source of this affection is a chronic laryngeal catarrh, 
leading to the development of a localized morbid process, prob- 
ably in the connective-tissue layer of the mucous membrane, 
resulting in the condition above described. The symptoms to 
which it gives rise are confined entirely to the voice ; there is 
no dyspnoea, no reflex spasm, no cough, as a rule, no pain, 
simjDly hoarseness or aphonia, resulting from mechanical inter- 
ference with free vibration and proper approximation of the 
cords. 

The affection is easily recognized, and a mistake in diagno- 
sis need not occur. I have frequently seen a small globule of 
thick, tenacious mucus adhering to the vocal cord in such a 
manner as to accuratel}^ resemble the morbid condition above 
described. Tliis disappears, of course, by simple cleansing by 
the spray or brush. 

The treatment of this condition consists in the local appli- 
cation of a strong solution of nitrate of silver of the strength 
of fifty to sixty grains to the ounce ; this should be applied by 
means of a small pellet of cotton wrapped on a slender laryn- 
geal probe, in preference to either the brush or sponge. In this 
manner the application is nicely localized at tlie diseased point, 
while the surrounding tissue need not be touclied, tlius avoid- 
ing the spasm which strong solutions of nitrate of silver are so 
apt to excite when applied in the laryngeal cavity. 
24 



370 TUMORS OF THE LARYNX. 



The Removal of Laryj^geal Tumors. 

The use of the laryngoscope which has rendered the accu- 
rate diagnosis of these morbid growths in the larj-nx possible 
during life, has also been followed by the invention of ingeni- 
ousl}^ constructed instruments, by means of which their removal 
is easily accomplished through the natural passages. 

It is a question whether the simplicity and attractiveness of 
these so-called endo-laryngeal operations for the removal of 
tumors, have not induced many oj^erators to resort to them 
when other and simpler methods of procedure might have 
been made use of, as in many cases, probably, small growths, 
the result of localized morbid processes, have been subjected 
to evulsion when local medication would have accomplished 
the desired end quite as satisfactorily and with probably far 
less injury to the delicate structures of the larynx ; it is not, 
however, intended to deprecate the usefulness of the endo- 
laryngeal operation, or to deu}^ that it is an immense advance 
in conservative surgery. The introduction, however, of this 
method of operation, was received with great enthusiasm, and 
was followed by an eagerness on the part of those who sought 
to establish a reputation in this special branch of medicine, to 
meet with a laryngeal tumor, and to cap the climax of their 
other achievements by removing it by the endo-laryngeal 
method. 

Nicety and accuracy of manipulation is not always possi- 
ble in removing laryngeal tumors, and in many cases, while 
the growth itself is removed, more or less of the healthy tissues 
are also torn away with consequent injury to the laryngeal 
structures. Hence, as before suggested, in the enthusiasm for 
operating it is probable that many cases have been subjected 
to unnecessary^ violence which might have been treated by 
simple local applications with equally good results, as regards 
the growth, and less injury to the healthy portions of the 
larynx. The instruments which have been devised are numer- 
ous. The general principle on which they are constructed is 
such that they can easily be passed within the laryngeal cavity, 
and by a simple and effective mechanism may be made to 
seize upon the tumor with the forceps, embrace it with a wire 
loop, or sever its attachment by the knife or guillotine. There 



THE EEMOVAL OF LAEYNGEAL TUMOES. 



371 



are two plans on which these instruments are constructed, that 
of the ordinary jointed forceps and the more elaborate tube 
forceps^ so-called. 




Fig. 146. — Tobold's laryngeal forceps. 



Fig. 146 represents Tobold's forceps, an ordinary pair of 
long forceps with serrated edges and curved for passing into 
the laryngeal cavity. Fig. 147 represents Fauvel's forceps, 




Pio. 147.— Prtuvers laryngenl forceps: A, handle, Hhu 
oral blades ; C, antero posterior-bladea. 



ing the method of locking the blades; B, 



constructed with a catch on the inner side of the ring handle, 
by which, after grasping the tumor, they are held in a closed 
position without further thought upon the part of the manipu- 



372 



TUMORS OF THE LARYNX. 



later. The bite of the instrument is also supplied with small 
teeth mounted upon one jaw and passing through openino-s 
in the other, intended to hold the growth more securely when 
once seized. 




Fig. 148.— Cusco's laryngeal forceps. 

^ Fig. 148 represents Cusco's forceps, which are constructed 
with a double hinge, so arranged that the jaws open near the 
distal extremity of the instrument. The advantage of this 




Fig. 149.— Mackenzie's laryngeal forceps': a, the lateral forceps ; 6, the anteroposterior forceps ; 
?poon-shaped forcaps ; d, punch forceps. 



mechanism is apparent. A very limited movement of the 
hand is necessary for the widest opening of the jaws of the 
instrument, hence less obstructed movement is obtained of the 



THE EEMOVAL OF LAEYNGEAL TUMOES. 



373 



point of the instrument during manipulation within the larynx. 
I have this instrument constructed with Fauvel's self -retaining 
catch on the rings, which add smuch to its usefulness. Mac- 
kenzie' s forceps shown in Fig. 149, are constructed with a more 
abrupt angle and with some modifications of the jaws, other- 
wise, however, resembling the other instruments. 




Fio. 150. — Mackenzie's laryngeal forcepe in position. The dotted linos illustrate the position of the 
ordinary curved forceps. (Mackenzie.) 



It is claimed by Mackenzie that the proper angle for tlie for- 
ceps is nearly the right angle. This is the princij^le on whicli 
his instrument is constructed, with the design of so fasliioning 
it that it can be more easily introduced, and that it more per- 
fectly escapes contact with the sensitive parts at the root of the 



374 TUMORS OF THE LARYNX. 

tongue when in situ. This is shown in Fig. 150. An}^ of these 
forceps may be constructed with the blades opening antero- 
posteriorly or laterally, to enable them to seize growths in any 
position of attachment. These jointed forceps possess every 
requisite of strength and efficiency for the removal of warty 
growths or pedunculated tumors, and will be preferred by most 
operators to the more delicately constructed tube forceps. The 
only objection which lies against them is, they are somewhat 
bulky and heavy for nice manipulation, and they are intended 
to seize and tear away the tumor which, of course, is only ac- 
complished with a certain amount of injury to the surrounding 
healthy tissues. In Fig. 151 is shown Mackenzie's tube for- 





Fig. 151. — Mackenzie's tube forceps. Pressure on the lever forces the tube forward over the blades, 
thus bringing them together. 

ceps, with the different mountings to adapt it for the varying 
size, character, and location of growths. Of all the instru- 
ments of this kind, this is probably the most efficient on ac- 
count of the delicacy of its construction, the simplicity of its 
mechanism, and the ease of its manipulation. Its working 
will be understood by reference to the plate. Fig. 152 rejDre- 
sents Stoerck's forceps. This is a somewhat more elaborate 
instrument of the same class, and is fitted not only with the 
seizing forceps of Mackenzie's instrument, but also with the 
guillotine for embracing polypi, and with the knife. It is 
somewhat more complicated than Mackenzie's instrument, is 
not so easy of manipulation, and not more efficient. 

Fig. 153 represents Mackenzie's guarded wheel ecraseur, 
for use in the larynx, whose action explains itself. In general 
it may be said in regard to the removal of laryngeal growths, 
that the jointed forceps will be preferred in the majority of 



THE REMOVAL OF LARYNGEAL TUMORS. 



375 



cases, on account of the strength of the instrument and the 
certainty of its grasp. In the case of the larger tumors, such 
as large masses of warty growths, or fibroids, their removal will, 
as a rule, require the use of the blade forceps. In the smaller 




growtlis, especially those which are pedunculated, the tube 
forceps will receive the preference as admitting of a nicer man- 
ipulation, and enabling the operator to remove the growth with 
less danger of injury to the surrounding healthy tissues. The 
location, character, and size of morbid growths in the larynx, 



376 



TUMORS OF THE LARYNX. 



vary so greatly, that it is difScult to lay down any special rules 
for their removal. Every physician, however, who has had any 
experience in the use of the laryngoscope, may safely trust his 
best judgment in the selection of the instrument best adapted 
for the purpose which he desires to accomplish. The great ob- 
stacle in the removal of tumors bj^ the endo-laryngeal method, is 
the irritability of the throat. As a rule, the tolerance of the in- 
struments requisite for the proper accomplishment of the man- 
ipulation, is only acquired after considerable training. It is 
absolutely necessary that the patient should hold his faucial 
muscles at perfect rest until the tumor is seized ; of course, 
very few patients are cajDable of this amount of control, hence 
it will be necessary to subject them to daily practice in the 




Fig. 153. —Mackenzie's ^larded wheel ecrasour. The wire loop is concealed within the metal rincr, to 
facilitate its management in the laryngeal cavity. After it is in place, the wire is drawn in by turning 
the wheel with the finger. 



passage of a probe into the larynx until they submit to the 
contact of the instrument without retching. When this toler- 
ance is acquired the operation is comparatively an easy one. 
The method of operating is simi^ly to guide the point of the 
instrument by means of the mirror held in place by the left 
hand, the patient protruding the tongue and holding it in his 
right hand. AYith the greatest amount of training it often 
happens that the requisite tolerance is not acquired on the 
part of the patient, and in these cases the operator's special 
skill is brought into requisition. Having thoroughly examined 
the growth, and being satisfied as to its location and attach- 
ment, it becomes necessary that he should possess sufficient 
skill to pass the forceps down, and seize the tumor during the 
momentary confusion which results from the retching of 
the patient ; that is, knowing the exact point at which he de- 
sires to engage the bite of the instrument, he proceeds with 



THE REMOVAL OF LARYNGEAL TUMORS. 377 

the manipulation without the aid of the guidance afforded by 
ocular inspection through the laryngeal mirror. This method 
of operating is open to the objection of being unsurgical, but it 
is the method which is required in a proportion of cases ; for, 
whereas the patient will submit to the passage of the probe 
which he knows is simply passed to accustom the larynx to its 
presence, he is extremely liable to become somewhat nervous 
when the forceps are passed, and will probably retch just at the 
instant when it will cause the most annoyance to the operator. 
From this consideration it is well to use the forceps as a laryn- 
geal probe in training the patient, and furthermore, to conceal 
from him the time when the operation is to be attempted. 
Small warty growths or pedunculated fibroids can, as a rule, 
be removed at a single operation. The larger tumors, how- 
ever, can only be removed piecemeal, and may often require 
a number of sittings. In those tumors which have attained 
a large size, and whose attachments are so extensive as to 
render their removal by the endo-laryngeal method diflB.cult 
and hazardous, resort must necessarily be had to the exter- 
nal operation. This consists in opening the larynx by cut- 
ting through the thyroid cartilage according to the method to 
be described. 

Before leaving the subject it may be well to remark that 
many attempts have been made to produce tolerance on the part 
of the laryngeal cavity of the introduction of instruments for 
the x)urpose of operating, by means of the local application of 
certain ansesthetic remedies, such as chloroform, ether, mor- 
phine, bromide of potassium, solution of tannin, alum, etc. 
What has been said already in regard to local measures for 
overcoming irritability of the fauces is true also of the larynx, 
viz., that we possess no method of attaining this result. The 
action of remedies so used is extremely uncertain, and even 
when anaesthesia is produced, it is largely tlirough the sys- 
temic action of the drug ; hence, as for instance in the use of 
morphine, there is danger of administering an excessive dose, 
and of getting too profoundly the systemic effect, before the 
local anaesthesia is produced. The only rule, tlierefore, Avhich 
can safely be followed in the endo-lar^nigeal method of remov- 
ing tumors is to study the character, position, and attachments 
of the neoplasm, calculate nicely tlie exact curve required in 
the instrument used to enable it to reach the point at which it 



378 TUMOES OF THE LARYNX. 

is desired to seize the mass, and tlien carry it quicklj^ and un- 
hesitatingly down, and by as rapid a movement as possible 
seize the tumor and remove it. 

Rossbach's Opeeatiots". — In this connection there should be 
mentioned a rather novel method of removing tumors from the 
larynx, recommended by Prof. Rossbach, of Wiirzburg. The 
procedure is only applicable to cases in which the neoplasm is 
attached to the upper surface of the vocal cords. The oper- 
ation consists in the introduction from without, into the cavity 
of the larj'ux, of a narrow-bladed, sharp-pointed, delicate knife, 
which is passed through the median lamina of the thyroid car- 
tilage, a few millimetres below the notch, and exactly in the 
middle line. The operation is not painful and the patient is only 
conscious of the pricking of the integuitient externally. The 
point of insertion is so selected that the blade shall appear in 
the laryngeal cavity immediatel}^ upon the upper surface of 
the cords. The further manipulation of the knife consists in 
the severing of the attachments of the growth, and this is said 
to be easily accomplished by the aid of the laryngeal mirror. 

The operation is an extremely simple one, is attended with 
no hemorrhage, the patient is unconscious of the presence of 
the knife in the larynx, and neither retching or cough is liable 
to be excited. It would seem that this operation might be 
eminently adapted for many cases, and might occasionally be 
preferred to either the endo-laryngeal method or the external 



Semi-Maligxaxt Tumoes of the Laeynx. 

But one class of neoplasms is embraced under this head, 
viz., sarcomata. The prominent clinical characteristic of these 
growths is their semi-malignancy, and hence the name is re- 
tained. They occur very rarely in the larynx. In the chap- 
ter on extirpation of the larynx five cases are reported in 
which this operation was performed for the removal of tumors 
of this class. They spring from the deep layers of the mu- 
cous membrane, or from the perichondrium, and extend 
slowly, but as a rule more rapidly than carcinomatous 
growths. They possess a marked tendenc}^ to infiltrate neigh- 
boring parts, hence they may not only encroach upon the 
cavity of the larynx, but may invade the adjacent tissu^Si 



MALIGNANT TUMOES OF THE LARYNX. 379 

They may be encapsulated, in which case they present a 
somewhat rounded mass ; or they may be without an invest- 
ing capsule, in which case they are more diffuse. They are 
composed largely of certain rounded, fusiform, or myeloid 
cells, with an intercellular substance and numerous blood-ves- 
sels. The round-cell sarcoma is the most malignant in charac- 
ter ; the fusiform or spindle cell tumor less so, and the myeloid 
the least malignant of all. The appearance of a sarcomatous 
tumor is by no means constant. It may present a rounded, 
smooth mass, resembling a fibroma, or a broadly diffused, 
irregular mass, not unlike a papilloma. The diagnosis is not 
easily made on laryngoscopic examination alone, but will be 
based largely on the location of the mass, its amount of diffu- 
sion, and the clinical history of the case. A certain diagnosis 
will only be attained by securing a small portion of the tumor, 
and examining it microscopically. 



Malignant Tumoes of the Laeynx. 



Cancerous growths develop not only primarily in the la- 
Tjnx, but also secondarily by extension from other organs. 
Of all neoplasms occurring in this organ a far larger pro- 
portion assume a malignant character than would be sup- 
posed, and it is not an unreasonable inference that the con- 
stant functional activity of which the organ is the seat, and 
the irritation to which any morbid process is subject, may 
have some possible influence in giving a malignant impetus 
to neoplastic development. Whatever may be the cause, how- 
ever, of this disease, its comparative frequency is undoubted. 
The forms which malignant disease may assume are epithe- 
lioma and scirrhus, including under the latter the encepha- 
loid form of cancer. A large j^roportion of cases can be 
traced to hereditary influence ; occasionally we may trace 
their incipiency to traumatic causes ; in others, no assignable 
cause can be given for their development. They may occur 
at any age from five to eighty, the majority of cases, how- 
ever, occur between the ages of fifty and seventy. In gen- 
eral it may be stated that cancer in the laiynx obeys the 
same laws as to causation, 2:)rogress, and duration, as govern its 



380 TUMORS OF THE LARYNX. 

manifestation in other organs of the body. In looking up the 
reports of laryngeal tumors somewhat hurriedly, I find re- 
ported four hundred benign neoplasms and one hundred malig- 
nant tumors, which indicates the comparative frequency of 
occurrence of the two forms of growths. Of the malignant 
growths the epithelioma occurs with the greatest frequency. 
Perhaps in no location do cancerous growths display their es- 
sential malignity more markedly than in the larynx, for in 
their dev^elopment they soon encroach both upon the oesopha- 
gus and the larjaix, thus interfering with respiration and deg- 
lutition, cutting off from the sufferer not only food but air. 
They may occur as prominent circumscribed masses, but more 
frequently they are broadly diffused. They may have their 
origin in any portion of the cavitj^, as the vocal cords, ventri- 
cles, ary-epiglottic folds, etc. 

Symptoms. — As the tumor develops, the symptoms which 
at first are extremely obscure become prominent, according to 
the character and location of the growth. The voice is liable 
to become affected very early, either from direct implication of 
the cords, or from the mechanical interference with their clo- 
sure. This is followed soon by interference with deglutition, 
the mechanical impediment to the act being rather more promi- 
nent than any X3ain attendant upon it ; this is especially true 
if the posterior wall of the larynx is involved. If the tumor be 
of the scirrhus or encephaloid variety, the mechanical obstruc- 
tion to phonation and deglutition increases until the passage 
of solids becomes impossible. If the cavity of the lar3aix is 
encroached upon, dyspnoea soon becomes a prominent symp- 
tom. If the disease be of the epithelial variety ulceration is 
apt to occur early in its progress, when pain becomes the 
prominent symptom of the affection. The sjanptoms vary to 
such an extent, however, with the character and location of the 
disease that it is extremely difficult to base an opinion on the 
subjective symptoms. Secondary infiltration of the glands of 
the neck does not, as a rule, occur very early in the history of 
the affection ; sooner or later, however, this is apt to occur, 
and there is presented that peculiar, hard, dense mass which is 
so characteristic of the secondary infiltration from malignant 
disease. Pain in the larynx, oftentimes of a sharp and lanci- 
nating character, is said to occur earl}^ ; this I have not noticed. 
The impairment of the general health maiaifesting itself ia. 



MALIGNANT TUMOES OF THE LAETNX. 881 

that peculiar I'acies whicli we call the cancerous cachexia, is 
among the later manifestations. 

Laryngoscopic examination.— In epithelial cancer there 
will be brought into view the characteristic appearances of that 
form of growth, varying in size, location, and attachment, 
but when seen satisfactorily it is recognized with compard,tive 
ease, in the characteristic gray pultaceous mass. Occasion- 
ally the tumor is more of a reddish or rose color, presenting 
minute injected points. Oftentimes it presents no well-de- 
lined outlines, but simply shows itself as an irregular mass 
incorporated in one of the walls of the larynx, distorting and 
partially occluding its calibre. The mucous membrane sur- 
rounding it is somewhat injected and marked by enlarged 
blood-vessels leading up to the tumor. Its tendency is to 
early ulceration, in which case the ulcerated surface is simply 
characterized by a discharge, somewhat scanty in amount, of 
thick, tenacious, ropy mucus. 

The diagnosis is not always easy on direct inspection, and 
yet it can be much aided by excluding syphilis and papillo- 
mata. From syphilis it is easily distinguished by the absence 
of those appearances which characterize syphilitic ulceration, 
as the excavated ulcer, sharp-cut edges, reddened areola, etc. 
From papilloma it is distinguished by the injected blood-ves- 
sels leading up to it, by the peculiar color of its surface, the 
minute red papillated projections, by its soft pultaceous charac- 
ter, and its tendency to hemorrhage, together with the involve- 
ment of the cervical glands and the general condition of the 
patient. In encephaloid cancer there is presented one or more 
rounded masses embedded beneath the mucous membrane of 
some portion of the laryngeal cavity which it displaces. It 
usually shows a number of highly injected blood-vessels cours- 
ing over its surface, and is attended with more or less diffuse 
infiltration of the lining of the larynx, so that the larj^ngeal 
cavity is not only encroached upon by the tumor, but is also 
markedly distorted and misshapen by the diffuse infiltration. 
It is oftentimes extremely difficult in the early stages of this 
affection to make a differential diagnosis between it and syphi- 
lis, and the decision will rest largely on the clinical history of 
the case and the subjective symptoms. As these tumors de- 
velop, however, they are apt to undergo, at one point or an- 
other, ulcerative action, when the appearances become quite 



382 TUMOKS OF THE LARYNX. 

distinct from those of syphilis. There is the absence of tliose 
appearances which are described as characterizing deep ulcer- 
ation of syphilis, and in place of which there is seen, in connec- 
tion with the more or less extensive and deforming tumors and 
infiltration, points of ulceration characterized by a certain 
amount of loss of tissue, with, however, no excavation, a mod- 
erate amount of discharge with no areola. The course of the 
cancer is to progress slowly and to produce death by apnoea, 
unless relief is given by tracheotomy, in which case death 
finally occurs from exhaustion, the average duration of the 
disease being three years. 

Treatment. — These tumors have been removed by the endo- 
laryngeal method, in which case, occasionally, the disease seems 
for a time arrested. It almost invariably, however, recurs, 
and the only result of the operation is temporary relief. Local 
measures for the removal of the accumulated secretions and 
the relief of pain, are of the greatest benefit, and should never 
be neglected. These consist in the application to the diseased 
surface, by means of the laryngeal spray, of one of the cleans- 
ing solutions given in the Appendix, followed by the applica- 
tion of iodoform, if ulceration exists, in connection with ano- 
dynes, of which preference should be given to morphine, either 
in powder or solution. Mild astringents are of benefit in con- 
trolling the secretions from the mucous membrane surround- 
ing the tumor, and add much to the comfort of the patient. 
Tracheotomy, of course, should be resorted to as soon as dysp- 
noea sets in. The question of operation should be considered 
only with reference to such temporary benefit as may accrue to 
the patient from it. Meddlesome interference with the malig- 
nant tumor oftentimes may result in serious injury, and it be- 
comes a question whether the comfort of the patient is not 
served better by mere palliative local treatment, which will 
often be attended with most excellent results, than by the at- 
tempt at removal, which can only be partially successful and 
which is attended with the danger of exciting renewed activity 
in the growth by which it may recur and develop far more 
rapidly than before. The question of the more radical treat- 
ment, by the extirpation of the larynx, will be discussed 
in another chapter. 



CHAPTER XXIII. 

ARTIFICIAL OPENINGS INTO THE AIR-PASSAGES. 

It is not intended to enter npon any lengthy consideration 
of all the surgical procedures which may be resorted to in the 
region of the larynx, but in as brief and concise a manner as 
possible to describe those operations which consist in opening 
the upper air-passages from without, in connection with the 
special indications for their performance. These operations 
consist of, laryngotomy, laryngo-tracheotomy, tracheotomy, 
tliyrotomy, and subhyoidean 2^haryngotom,y. The upper air- 
passages are opened by one of the above operations for the 
purpose of removing tumors or foreign bodies, and to relieve 
dyspnoea, the selection of the special operation being gov- 
erned by the characteristics of the object to be obtained. The 
last two operations enumerated are performed for the sole pur- 
pose of removing neoplasms and foreign bodies, or to remove the 
results of morbid conditions which interfere with respiration or 
phonation, such as cicatrices from syphilis, resulting in steno- 
sis, etc. These operations, of course, are only resorted to in 
those cases in which the endo-laryngeal operation presents ob- 
stacles too great to be surmounted. Lar3nigotomy, laryngo- 
tracheotomy, and tracheotomy, are performed for the purpose 
of relieving dyspnoea, though occasionally for the removal of 
foreign bodies or tumors. 

The anatomical points (see Fig. 154) to be remembered in 
connection with these operations are as follows : The larynx 
and trachea lie somewhat superficially in the neck, covered 
with the integument and the superficial cervical fascia. From 
above downwards we have the thyroid cartilage, crico- thyroid 
membrane, and the trachea, the second and third rings of which 
are covered by the isthmus of the tliyroid gland. The tli^^-oid 
cartilage with the thyroid notch is easily recognized by tiie 



384 AETIFICIAL OPENINGS INTO THE AIR-PASSAGES. 

toucli immediately beneath the skin. From three-fourths of 
an inch to an inch below the thyroid notch or Adam's apple, is 
felt a slight depression which indicates the position of the cri- 
co-thyroid membrane. Immediately below this is felt the cri- 
coid ring surmounting the rings of the trachea. 

The crico-thyroid membrane is traversed by the crico-th}^- 
roid artery, a small artery whose division occasionally gives 
rise to troublesome hemorrhage. In front of the trachea lie 
the sterno-tliyroid and sterno-hyoid muscles whose anterior 
edges approximate in the median line. Beneath these and at 
the sides of the trachea lie the anterior jugular veins, approxi- 
mating above and diverging below to pass beneath the sterno- 
mastoid muscles ; they are occasionally connected by a trans- 
verse branch. The cutting of these veins is to be avoided, as 
a considerable hemorrhage might result. 

The isthmus of the thyroid gland lies upon the second and 
third rings of the trachea, and is covered by a plexus of veins 
which converge below to a single vein, which descends in front 
of the trachea, and empties into the innominate vein. Imme- 
diately above the isthmus is found the transverse communi- 
cating branch between the superior thyroid veins. 



Laeyngotomy. 

Laryngotomy consists in making an opening through the 
crico-thyroid membrane, and is the simplest and easiest of all 
the operations. The method of performing it requires no 
lengthy description. The head being bent well back, and the 
crico-thyroid space being located, an incision in the median line 
of an inch to an inch and a half in length is made, and the 
membrane divided by an opening sufficiently large to admit the 
introduction of a tube. The operation is attended with no es- 
pecial dangers or difficulties, other than the division of the cri- 
co-thyroid artery, which, however, usually gives rise to but 
trilling hemorrhage. If the operation is done merely for tem- 
porary relief to laryngeal obstruction, it is the one to which 
preference should be given. If, however, the patient requires 
that the tube should remain in situ for any lengthened period 
of time, there is danger of its not being well tolerated, as ulcer- 
ation and necrosis of the cricoid cartilage might ensue. 



TEACHEOTOMY. 385 



Laryngo-Tracheotomt. 

This operation consists in opening the air-passages by means 
of an incision throngh the cricoid cartilage and upper ring of 
the tracliea. Its method of performance is much the same as 
in laryngotomy. The regional anatomy of the parts having 
been determined beforehand, the incision throngh the integu- 
ment is carried somewhat lower down, and the cartilages hav- 
ing been laid bare, are cut through by means of a sharp-pointed 
bistoury plunged between the first and second rings of the 
trachea and carried upward until the cricoid ring is cut through. 
One of the dangers or difficulties attending the operation is 
the occurrence of hemorrhage from the communicating branch 
between the superior thyroid veins, from which troublesome or 
even dangerous bleeding may arise. In addition to this the 
proximity of the thyroid gland is such, that it is extremely lia- 
ble to be cut during the operation, becoming an additional 
source of what may be an extremely troublesome hemorrhage. 



Tracheotomy. 

This operation consists in opening two or three rings of the 
trachea below the isthmus of the thyroid gland. The method 
of performing it is as follows : The head being thrown well 
backward, by which the trachea is made as prominent as pos- 
sible, an in(;ision is made carefully in the median line from the 
cricoid cartilage downward to the extent of two or two and 
a half inches. The integument and superficial fascia having 
been cut through, the next step of the operation should be to 
expose the trachea as far as possible by the use of the handle 
of the scalpel and fingers, crowding to one side the anterior 
jugular veins and the border of the sterno-hyoid muscles, and 
removing the loose areolar tissue, and crowding to one side also 
the inferior thyroid veins. The trachea having been exposed, 
it is incised from below upward by a sharp-pointed bistoury 
and tlic tube inserted. The dangers of this oi)eration lie in the 
]u)ssil)l(> injiiiy of the thyroid isthmus which may be found 
i\ing low down on the trachea, and tin? cutting of the thyroid 
25 



386 



ARTIFICIAL OPENINGS INTO THE AIE-PASSAGES. 



veins which might result in excessive or troublesome hemor- 
rhage. 

Fig. 154 will show the relative position of the parts, and 
the course of the vessels with reference to these various opera- 
tions. 

Instruments Used. — For the simple operation in trache- 
otomy, there is required only a scalpel and a tube, together 
with towels, sponges, and tapes. A fully furnished tracheotomy^ 
set, however, should contain scalpels, a sharp and probe- 



f^"' 

\\\' 



ThjToid cartilage. .11 



Crico - thyroid 1 \ 

membrane aud > - -V 
artery. ) 

Cricoid cartilage " " 

Superior thyroid I 




Inferior thyroid ) 
vein . j" 



Innominate artery.. 




Thyroid body. 

(Isthmus. ' 



Fig. 154.— Surgical anatomy of the laryngo-trachcal region. (Gray.) 



pointed bistoury, artery forceps, tenaculum, retractors, a sup- 
-ply of tubes of different sizes, and sponges, tapes, and 
feathers.. 

Cutting instruments include an ordinary-sized bistoury for 
making the incisions down to the trachea, after which the rings 
should be cut through by means of a sharp-pointed bistoury, 
a probe-pointed bistoury being at hand for the purpose of en- 
larging the opening, if necessary ; for while, of course, this can 
be done by the sharp-pointed instrument, the former is safer. 



TEACHEOTOMY. 



387 



The retractors shown in Fig. 155 are of service in holding open 
the wound, especially if the trachea lies deeply ; these, of 
course, are held by an assistant. The tenaculum serves the 
purpose of holding the trachea steadily while it is being 
opened. The tracheal dilator is for the purpose of dilating 
the tracheal opening to facilitate the insertion of the tube. 



Fig. 155. — Piloher's tracheal retractor. 

Various forms of this instrument have been devised by La 
Borde (Fig. 157), Hutchinson (Fig. 158), and others, none 
of which probably are more efficient than the original instru- 
ment of Trousseau (Fig. 156). 

After the trachea has been opened, the selection of the tube 
and its proper introduction is, perhaps, as important a feature 




Fig. 15(i.— Trousseau's tracheal dilator. 




La Dordc's tracheal dilator. 



of the operation as any otlier. The original trachea tube con- 
sists of a metallic cylinder bent to complete tlie quadrant of a 
circle and fitted with a collar at its cervical end. This collar is 
provided with small openings on eacli side into which tapes 
are inserted and passed around the neck and tied, thus holding 
the tube in position. This is the instrument shown in Fig. 159, 
and is generally known as Trousseau's canuki. The collar is 



388 



ARTIFICIAL OPENINGS INTO THE AIE-PASSAGES. 



fastened firmly to tlie tube, so tliat in the movements of deglu- 
tition, the trachea being raised together with the tube, the col- 
lar is apt to chafe the borders of the wound. A modification 
of this tube was made by Roger, a French surgeon, which con- 
sists in making the collar movable, thus enabling the trachea 




Fig. 158.— Hutchinson's tracheal dilator. 



tube to move with the movements of the trachea while the col- 
lar lies firmly against the neck (see Fig. 160). This is accom- 
plished by fitting around the cervical end of the tube a loose 
neck-plate which is held loosely in position by two flanges 





Fig. 159. — The original Trousseau tracheal canula, a single tube with immovable necklet. 
Fig. 160. — Roger's tracheal canula, a single tube with movable neck-piece. 

passing over small projections from the narrow collar fastened 
directl}^ to the tracheal tube itself. In addition to this mova- 
ble neck-jDlate, another improvement was made by M. Ober, 
which, perhaps, is the most imj^ortant of all, and which con- 
sists in suppl3dng an inner tube which can be taken out at will, 



TRACHEOTOMY. 



389 




Fig. 161. — Ordinary double tracheal canula. 



in order to remove accumulations of mucus, while the outer 
tube remains in position. There is thus avoided the incon- 
venience and oftentimes danger of the removal of the single 
tube for cleansing purposes, which 
becomes absolutely necessary at 
times. This double tube with the 
movable neck-plate is the instru- 
ment now generally used, and in 
most cases leaves little to be de- 
sired (see Fig. 161). A number of 
devices have been suggested, and 
changes made since the invention of this tube, prominent 
among which is that of Durham (Fig. 162). The important 
feature of this tube consists in making that portion of it 
which lies in the wound straight, while the tracheal end is 
bent somewhat abruptly to a right angle. At the same time, 
in order to adapt it to the varying depth of the trachea be- 
neath the integument, it is so arranged that the position of 
the neck-plafce can be changed, thus altering the length of the 
straight portion of the tube, and adapting it for any case, 

whether the trachea may 
lie deeply or superficially. 
When the proper position 
of the neck-plate is arrived 
at, it is fastened by a screw 
shown in the figure. Of 
course this right - angled 
outer tube requires that 
the inner tube, in order to 
allow of insertion or re- 
moval, shall be flexible. This is accomplished by making the 
tracheal end of the inner tube jointed lobster-tail fashion as 
shown in Fig. 163. 

This tube is also supplied with a pilot trocar, shown also in 
Fig. 163, with a jointed extremity, to aid the introduction of 
the tube into the ti-achea. Theoretically, Durham's tube is 
undoubtedly a great improvement on the ordinary form. The 
great advantage of it is, that in the movements of deglutition 
the tube moves upward in the axis of the trachea, carrying 
with it the tracheal end, wliich is thus prevented from tilting 
against its posterior wail, which so often becomes a source of 




Fig. 162. — Durham's tracheal canula. 



390 ARTIFICIAL OPENINGS INTO THE AIK-PASSAGES. 

irritation or ulceration in wearing tlie older form of tube. 
Another very great advantage is in the movable neck-plate, 
which renders it possible to nicely adjust the tube to the vary- 
ing thickness of the cervical tissues, and thus enables it to be 
placed in such a manner that the tracheal opening reaches the 
trachea and no further. The objection to Durham's tube is in 
its jointed inner canula, which presents crevices for the lodg- 
ment of mucus, so that it easily becomes clogged. There is 
also a danger that the segments may become detached and 
drop into the trachea. In addition to this, the removal and re- 
insertion of the outer tube, after the wound in the neck has 
closed around it, is attended with some distention of the parts 
which renders it necessary to crowd it to such an extent that 
hemorrhage may be excited. In Trousseau's tube, by passing 
it -exactly in the line of the circle of which it forms a quad- 




FiG. 163.— Pilot trocar and inner canula for Durham's tracheal canula. The trocar is shown with the 
canula upon it. 

rant, no lateral pressure whatever is exerted, and the tube is 
removed and reintroduced with perfect ease, and without ex- 
citing pain or hemorrhage. With the Durham tube, on the 
other hand, which is passed through a straight opening until it 
reaches the trachea, its convexitj^ crowds upon the upper wall, 
while its tracheal extremity scrapes along the floor of the 
wound until it reaches its position. 

Another modification of the tracheal canula is Fuller's bi- 
valve tube. This consists of an ordinary canula in which, how- 
ever, for the outer tube there is substituted two lateral plates 
which may be brought into close proximity or separated to 
any distance by means of a screw attached to the cervical plate. 
The plates being brought into close apposition before inser- 
tion, and when fairly within the trachea, they are separated 
to an}^ desired distance in order to receive the inner tube. The 
advantage of this tube is the great facility of its introduction, 




TRACHEOTOMY. 391 

and also that it is adapted to receive various sizes of the inner 
tube. The great objection to Fuller's device is the danger of 
the sharp edges of the movable plates cutting the tissues and 
exciting hemorrhage. A number 
of such accidents have been re- 
ported as occurring from the use 
of this tube. A similar device is 
that of Gendron, shown in Fig. 
164. In this instrument the outer 
tube is split into two lateral plates. 
The main object of this is to enable 
the operator to press together the 
extremities of the plates and thus fig. i64.—Gendron's bivaive tracheal can- 
facilitate its introduction. After 

it has been passed into the trachea, the plates are crowded 
apart by the introduction of the inner tube. This instruni. 't 
is open to the same objection as that of Fuller. 

An oval opening is oftentimes made on the upper side of 
the convexity of the trachea tube to enable the patient to 
breathe through the natural passages, or to talk. This open- 
ing is usually made in the outer tube alone ; it is, however, not 
only a useless, but an objectionable feature, as the edges of 
the opening are liable to press against the walls of the trachea, 
giving rise to ulceration. It is useless, also, for the reason 
that the canula should never fill the calibre of the trachea, 
and, as a rule, never does, so that an abundance of space 
is left between the walls of the trachea and the sides of the 
tube for the passage of air, and the tube will interfere to no 
greater extent with respiration or phonation, than does the 
condition which has demanded tracheotomy. The tube should 
be made of virgin silver or German silver. The use of vulcanite 
which has come much into vogue of late years in the manu- 
facture of tracheal tubes, is much to be deprecated. The only 
advantage of a rubber tube is in its cheapness ; the objections 
to it are tliat it is bulky, thereby requiring a larger opening 
than would be required for a silver tube of the same calibre. 
It is also fragile, and this is the greatest and the most serious 
objection to it. The mucus which accumulates about its trach- 
eal extremity is liable to make its way between the inner and 
outer tube, where, drying, it adheres closely and oftentimes 
renders the extraction of the inner tube for cleansing purposes 



892 



ARTIFICIAL OPENINGS INTO THE AIR-PASSAGES. 




difficult, and in the effort at removal the tube is liable to be 
broken. Its cheapness will retain it in common use, however ; 
it should therefore be watched with care and accidents pre- 
vented by frequent cleansing both of the inner and outer tubes. 
In many cases, and especially those in 
which the tube is necessarily worn for a long 
f ime, some device by which the current of air 
ill expiration may be directed through the 
natural outlet, is of great advantage. The 
object of this is, that talking may be pos- 
sible without the necessit}^ of placing the 
finger over the opening in the tube, and also 
that coughing and expectoration may have 
natural outlet through the mouth. Fig. 165 
illustrates Luer's valve, which is for insertion 
into the cervical end of the trachea tube. It contains a small 
ball, which in expiration is driven forward and closes com- 
pletely the ojDening, while in inspiration it falls back against 
the wire, shown in the figure, and allows of the free ingress of 
the current. 

Tracheotomy is very frequently demanded in pressing 
emergencies, and many lives have been sacrificed from the 
fact that the sudden call has found the surgeon unprepared. 



Fig. 165.— Luer's baU 
valve with side removed. 
m. mouth which fits into 
the end of the tracheal can- 
ula : 6, wire to limit the 
movement of the ball ; o, 
orifice. 




■PiG. 166.— Maclvenzie"s pocket canula, with pilot trocar inserted: K, knife inserted in the pilot; S, 
Blit in handle, which opens for withdrawal of the knife : W, W. wire flanges which serve the purpose of 
the cervical plate, and which fold back against the sides of the tube. 



With a view to such emergencies, Mackenzie has devised a 
very compact tracheal canula, supplied with a pilot trocar, 
which contains also a scalpel. For the cervical plate there is 
substituted two wire flanges which can be bent back against 
the sides of the tube. (See Fig. 166.) The whole comprises a 



TEACHEOTOMY. 



398 



simple affair wliicli can easily be carried in the vest pocket. 
Fig. 167 sliows the inner construction of the pilot trocar. 




Fig. 167. — Pilot trocar of Mackenzie's poclcet tracheal canula, showing the 
scalpel inserted into the handle of the instrument : S, slit in handle which 
opens to allow of the withdrawal of the scalpel. 

While a knife is, as a rule, always at hand in an emergencj^, 
the lack of a tracheal tube is often the 
source of serious embarrassment. Dr. 
Benjamin Howard, formerly of ISTew York, 
describes in The Medical Record^ Novem- 
ber, 1871, an ingenious canula which he 
had imj)rovised and used successfully in 
a sudden emergency. The method of pre- 
paring the tube as directed by Dr. How- 
ard is as follows : 

" Take a piece of lead, whether in the 
form of sheet, pipe, or bullet, and, if neces- 
sary, hammer it out as thin as it can be used 
without breaking. Of this cut a piece the 
shape of a parallelogram, and about two 
and a half by one and a quarter inches, or 
enough to allow a margin ; roll it around a 
trimmed stick, ramrod, or pencil, thus mak- 
ing a tube as in Fig. 168, and bevel both 
edges so that by trimming and dressing the 
seams may be smootii and iu'm. Cut the up- 
per end so as to form four slips of equal size, 
6, &, and at about the middle of the tube 
cut out a transverse elliptical section from 
about two-thirds of its circumference (Fig. 
168 c). Withdraw the pencil, and bend the 
tube upon itself. Turn down the slips, and 
in two of them cut eyelet holes, through 
which a string or tape may be passed 
around the neck to retain the canula in 




Fig. 108. — Prejiarationof How- 
ard's iniprovist'd tracheal cnnula 
from a sheet of lead rolled around 
a pencil: «,«, bevelled seam; 6,&. 
fluMRes for the formation of a cer- 
vical plate : <\ c, jiiece inciijcd to 
allow of bending the tube. 



its position in the 



wound." The finished tube is shown in Fig. 169. 



394 



AETinCIAL OPENINGS INTO THE AIR-PASSAGES. 



Anaesthesia. — A difference of opinion exists as regards the 
advisability of the use of anesthetics in the operations for 
opening the upper air-passages. Some writers condemn the 
use of general anaesthesia, giving preference to the local methods 
by the ether spray, rigolene, etc., while others advise its use 
on the ground that a more perfect control of the patient is 
thereby secured and those annoying movements of the trachea 
avoided which so often interfere with 
the operator. My own preference is 
very decided for the use of chloroform 
or ether in tracheotomy. A very limit- 
ed amount is required, especially if 
cyanosis exists to any extent, for in 
that case the patient is partially anaes- 
thetized by the carbonic acid retention. 
It has been also urged against anaes- 
thesia that the blood which may flow 
into the trachea during the operation 
is not expelled ; this is not a valid ob- 
jection, as reflex irritability is not en- 
tirely destroyed, but there is sufiicient 
remaining, as a rule, to cause expulsive 
effort on the part of the patient. And 
again, the operation at the time this occurs has been finished 
or should be, and even if anaesthesia has been complete, he will 
have rallied somewhat by the time the trachea is fully exposed, 
and from that time until the introduction of the tube should, 
in the hands of a skilful operator, be but a very brief space of 
time. 

In regard to the selection of the anaesthetic agent, with def- 
erence to the well-grounded American prejudice against the 
use of chloroform in ordinary surgical proceedings, it would 
seem to afford a safe and reliable agent, and one in every way 
to be preferred in operations about the upper air-passages. 

As a rule, in these operations a certain amount of dyspnoea 
exists already, resulting in more or less cyanosis ; hence, be- 
fore any anaesthetic is administered, a partial anaesthesia 
exists so that a very limited amount is required. Chloroform 
is speedy in its action, is not irritating to the mucous mem- 
brane, rarely causes vomiting or retching, and the only objec- 
tion lies in the possible dangers of its administration. Ether, 




Fig. j(19. — Howard's improvise 
tracheal camila : b, flanges and eye- 
let holes ; c, elliptical opening closed 
by bending the tube. 



TRACHEOTOMY. 395 

on tlie other liand, requires the administration of a larger 
amount, requires a longer time for the production of anaesthe- 
sia, is extremely irritating to the air-passages, exciting cough 
and other reflex symptoms, is liable to excite nausea and 
vomiting, and also causes that movement of retching by which 
the trachea and larynx is drawn up and down in a spasmodic 
way, as it were, thus greatly interfering with the surgeon's 
manipulations. For these reasons it seems to me that the use 
of chloroform is not only fully warranted, but might be safely 
recommended in preference to ether. 

When the symptoms which demand tracheotomy become 
extremely urgent, the time required to administer an anaesthetic 
would be too valuable time lost ; in these cases the operation 
should be proceeded with immediately and without such delay. 

HemoPwRHAGE. — Arterial hemorrhage may occur from sec- 
tion of the crico-thyroid artery ; this, however, is usually but 
trifling in character; it may also occur from the thyroidea 
ima, but rarely of sufiicient extent to cause serious trouble. 
Wounds of the innominate or carotid arteries are among the ac- 
cidents that have occurred in the performance of tracheotomy, 
but it would seem that such an accident could only be the result 
of the grossest carelessness. 

Venous hemorrhage, however, from the inferior or superior 
thyroid veins, or from the accidental wounding of the thyroid 
isthmus, will oftentimes prove exceedingly troublesome or 
even dangerous ; especially is this true if marked cyanosis 
exists as the result of extreme dyspnoea. In these cases the 
blood wells up apparently from all sides, filling the cavity of 
the wound so rapidly as to prevent recognition of the source of 
the bleeding. Of course if the case is not an urgent one, and 
the source of the hemorrhage can be detected, the vessels should 
be tied. It is usually laid down, as a rule, not to cut into the 
trachea until hemorrhage has been arrested, in order to avoid 
the danger of blood making its way into the air-passages. 
This rule cannot be followed in all cases, and oftentimes it be- 
comes absolutely necessary to proceed with the operation with- 
out reference to the hemorrhage. Guiding the manipulations, 
therefore, with the finger, it is justifiable and even obligatory, 
if the symptoms are urgent, to open the trachea and insert the 
tube as rapidly as possible, even though the wound is filled 
with welling blood. The result of this is, of course, that more 



396 ARTIFICIAL OPENINGS INTO THE AIR-PASSAGES, 

or less blood escapes into the trachea ; this, however, can be 
obviated by immediately turning the patient with the face 
downward and the body inclined, at the same time holding the 
tube in position by the hand, and closing the wound as firmly 
as possible around the tube. The escape of blood which has 
thus gotten into the trachea will be facilitated, and the hemor- 
rhage will soon be arrested. Tracheotomy may be one of the 
simplest of operations, or it may be an extremely formidable one; 
and there is nothing wdiich so complicates it or renders it diffi- 
cult as the oc(;urrence of this excessive hemorrhage confusing 
the operator, and masking and concealing the tissues operated 
upon, and it is only by the exercise of coolness and decision 
that these difficulties can be surmounted. Hemorrhage, how- 
ever, is not the bugbear that it is usually regarded, as all the 
difficulty which it canses will usually disappear under the 
exercise of promptness in proceeding with the operation, and 
finishing its steps rapidly where urgency exists or where the 
possibility of reaching the source of the bleeding for the liga- 
tion of vessels is impossible. 

With the view of preventing the entrance of blood into the 
trachea during the operation of tracheotomy, Dr. Hanks, of 
New York, has devised a tracheotome (Fig. 170), which he de- 
scribes as follows: "The instrument 
consists of a curved, hollow, sharp- 
pointed trocar, with handle (also hol- 
low) attached — the whole about three 
and a half inches in length. It is made 
to fit exactly the larger of the set of 
tracheotomy tubes. In operating, the 
better way will be to cut down upon the 
trachea, which must be held firmly with 
X. i~n Ti , w „ . the tenaculum, when the trocar with the 

Fig. 170. — Hanks' tracheotome. ' 

canula is forced through between any 
two of the rings of the trachea, after which the trocar may be 
withdrawn and the canula left in situ. The advantages of this 
device are : 1st, but little blood can enter the trachea during 
the operation ; 2d, the patient is supplied with fresh air di- 
rectly upon the trocar penetrating the trachea." 

Exposure of the Trachea. — After the topical points have 
been accurately located, viz., the thyroid notch, crico-thyroid 
space, etc., the exposure of the rings of the trachea is not usu- 




TRACHEOTOMY. 397 

ally a difficult matter. Yet if the patient has a stout, thick 
neck, or if any tumor exists, or infiltration of parts which may 
crowd it out of the median line, very grave difficulties are 
sometimes added to the operation. In reaching the trachea the 
knife should be used as sparingly as possible, preference being 
given to the handle of the scalpel and finger in crowding the 
tissues to one side, provided no emergency exists which re- 
quires rapidity of the operation. As the incision deepens the 
edges of the wound should be drawn back by the retractors 
(Fig. 155) in the hands of an assistant. 

Opening the Trachea. — When the trachea is reached, it 
should be seized with a tenaculum and drawn forward, thus 
steadying it, and enabling the operator to make the incision 
accurately in the median line, and sufficiently large to admit 
of the tube. Care should be exercised in cutting the rings, not 
to carry the point of the knife to the opposite side of the tra- 
chea, thus wounding parts which it is desired to leave intact. 
Cases have occurred where the opening has been made not 
only through the anterior wall of the trachea, but through its 
posterior wall and that of the oesophagus, the knife being car- 
ried down until it struck the vertebra. The point of the knife 
should be carried well through the tracheal wall and its mu- 
cous lining also, as the mistake has occurred of cutting through 
the tracheal rings only, the mucous lining being carried before 
the knife in such a way that when the tube was introduced 
the mucous membrane was pushed before it and complete oc- 
clusion of the trachea resulted for the time. If the operation 
is done with an abundance of light and prompt assistance, the 
physician will be able to see the steps of his operation and 
recognize exactly what has been accomplished. As the trachea 
is cut thi'ough the escape of air will dilate very moderately the 
opening and reveal the extent to which the incision has been 
made. Of course if hemorrhage occurs and urgency- has com- 
l^elled the operation to be finished beneath the blood welling 
out of the wound, the only guide will be the finger. 

The Introduction of the Tube. — This would seem to be 
the simplest stejD of the whole operation, and yet it may prove 
oftentimes an extremely difficult one. Cases have been re- 
corded in which the tube has been thrust into the areolar tis- 
sue surrounding the trachea in place of the traclieal opening. 
•To facilitate the passing of the tube, Trousseau's forceps (Fig. 



398 ARTIFICIAL OPENINGS INTO THE AIR-PASSAGES. 

156) are usually recommended. This instrument consists of a 
two-bladed pair of forceps, with diverging extremities, which 
are introduced into the tracheal wound for spreading its edges. 
La Borde has modified this by constructing a trivalve dilator as 
shown in Fig. 157, though what purpose the extra blade serves 
it is difficult to perceive. 

Fuller's or Gendron's bivalve trachea tubes are extremely 
easy tubes for introduction, but open to the objections already 
noticed. The pilot trocar shown in Fig. 171, very materially 
simplifies the introduction of the tube, but, of course, it is ne- 
cessary that every sized tube should have a separate trocar ; 
hence, unless one has a very liberally furnished case of instru- 




FiG. 171.— Pilot trocar for inserting the ordinary iraclieal canula. 

ments, the trocar to fit the special instrument which he designs 
to iise is liable to be wanting. Ordinarily, however, the canula 
will be introduced with comparative ease, and without a dilator 
or trocar, simply carrying the tracheal end of the tube on the 
forefinger as a guide, provided, of course, that the tracheal 
opening is sufliciently large. 

Selection of the Site for Operation. — It is difficult to 
lay down any definite rules as regards the operation to be per- 
formed : it is usually taught, however, that the trachea should 
be opened below the isthmus of the thyroid, in preference to 
the higher operation. Tliis is the more difficult operation, but 
it is less liable to be followed by ill effects afterward, it is said. 
The nearer the operation is to the vocal cords the greater the 
danger of impairment of the voice. This is undoubtedly an 
over-estimated danger. While, then, every case must be judged 
by the special incidents attending it, it seems to me that taking 
into consideration the simplicity of the operation, the rapidity 
with which it may be done, and the fewer complications that 
may attend it, that we might with safety more frequently re- 
sort to the higher operation. This is especially true if the oper- 
ation is merely to relieve a temporary laryngeal obstruction. 



THYROTOMY. 399 

If, however, there is a probability that the tube will need to be 
worn for any great length of time, the opening should be made 
below the isthmus, viz., tracheotomy. 



Thyrotomy. 

This oi)eration is only resorted to for the removal of neo- 
plasms or foreign bodies, and consists simply in opening the 
laryngeal cavity by an incision through the cricoid ring, crico- 
thyroid membrane, and the thyroid cartilage, thus splitting 
open as it were the larynx in the median line in front, and 
drawing apart the al^, exposing the laryngeal cavity. In 
many cases of tumors whose attachments are so broad or 
w^hich are so extensive in character that the endo-laryngeal 
operation becomes an extremely difficult one, this operation 
will necessarily be resorted to. Especially is this true of can- 
cerous tumors, or tumors in small children in whom the proper 
training becomes next to impossible, to prepare them for the 
endo-laryngeal operation. In these cases the only resort lies 
in opening the laryngeal cavity in the manner above noted. 
The operation is comparatively a simple one, and attended 
with no great danger. It gives free access to the cavity of the 
larynx and enables the operator to dissect out growths and 
remove them with a nicety and thoroughness which cannot be 
easilj^ obtained by the endo-laryngeal method. Yet it should 
not be resorted to, of course, unless the obstacles in the way of 
the performance of the simpler operations are too great to be 
overcome, as there is great danger of causing serious injury to 
the vocal apparatus, and even permanent impairment of the 
voice, if this has not already occurred, as the result of the mor- 
bid condition which the operation is designed to remove. The 
patient should be placed in Rose's position, with the head 
drawn over the edge of the table, and in sucii a manner that 
the tissues of the neck are placed on the stretch, thus throw- 
ing the larynx and trachea well forward in the neck, and in 
such a position that the axis of the trachea is inclined toward 
the head. The object of this position, of course, is, that in open- 
ing the air- passages, any blood that may flow will jjass into the 
mouth instead of trickling down the trachea. The anatomical 
points having been located, an incision is made from the cri- 



400 ARTIFICIAL OPENINGS INTO THE AIR-PASSAGES. 

coid cartilage to the hyoid bone. The hiryngeal cartilages 
having been exposed, a sharp-pointed bistoury is inserted 
below the cricoid cartilage, and the ring cut through, and the 
incision carried upward in the median line until the thyroid 
cartilage has been severed. This can ordinarily be accomplished 
by a. simple bistoury. If the patient is advanced in years, a 
stout pair of pliers should be at hand with which to make the 
incisions, in case the cartilages should be found ossified or the 
incision of the knife interfered with or prevented from any 
other cause. The laryngeal cavity having been thus opened, 
the wings of the thyroid cartilage can easily be drawn apart 
and the whole cavity exposed, thus enabling the operator to 
proceed with the subsequent steps of the operation, according 
to indications. An anaesthetic, of course, should be adminis- 
tered. 

Thyrotomy is occasionally done subsequently to tracheot- 
omy or laryngotomy, the earlier operation having been per- 
formed for the relief of dyspnoea, and the indications for the 
later operation being the removal of the conditions which gave 
rise to the obstruction. In this case the incisions Avill consist 
simply in extending the tracheal wound from below upwards, 
until the laryngeal cavity is exposed. If tracheotomy has not 
already been done, it may occasionally be desirable that it 
should be performed previously, in order that the subsequent 
thyrotomy may be accomplished, without the danger of too 
much blood escai3ing into the trachea. 

For this purpose Trendelenberg has devised an instrument 
especially designed for use, in operations about the upper air- 
passages. This apparatus, shown 
in Fig. 172, consists of an ordi- 
nary tracheal tube, around the 
tracheal end of which there is fit- 
ted a piece of distensible rubber 
tubing about an inch in length, 
fastened firml}^ at each end to the 
canula, rendering the space be- 
^ _^ ^ ^ , , , ^ tween the rubber tubing and the 

Fig. 1T2. — Trendelenberg's apparatus. " 

silver tube air-tight. Communi- 
cating with this space is a small tube passing doAvn with- 
in the canula, projecting bej^ond its cervical end, and pro- 
vided with a stop-cock. By means of an air-bulb attached 




THYROTOMY. 401 

to the cervical end of this small tube, air can be pumped into 
the distensible rubber tube for the purpose of distending it. 
The working of this is evident. After the canula has been in- 
serted into the trachea, the rubber tube is inflated by means 
of the air-bulb v^^ithin the trachea, thus plugging and pack- 
ing the space between the canula and the wall of the trachea, 
and completely preventing the possibility of the blood trick- 
ling from the wound into the air-passages. By this device 
the operator is saved the annoyance of all reflex symptoms 
such as coughing, choking, retching, etc. , which are caused by 
the flow of the blood into the trachea. This device of Trende- 
lenberg's is an ingenious one, and one which will often prove of 
great service in not only thyrotomy, but in any of the operations 
about the larynx which involve incision into the air-passages 
from without. The serious difficulty, however, in its use, is 
that it is not well tolerated. In two cases in which I have 
used it, the inllation of the rubber tube gave rise to such vio- 
lent attacks of dyspnoea that it had to be abandoned. The 
pressure from within outward, on the wall of the trachea, 
seemed to excite a reflex spasm, which caused total arrest of 
all respiratory movements, and that, too, while the patients 
were under the influence of an ansesthetic. That this is not 
usually the case, however, is evidenced by the number of 
operations reported, in which Trendelenberg' s apparatus has 
been used successfully. 

Dr. Lange, of this city, in an operation for extirpation of 
the larynx (Chap. XXIV., Case XXII.), resorted to the device 
of wrapping the tracheal end of an ordinary canula with punk, 
and inserting it into the trachea, thus providing a means of 
completely plugging the space between the sides of the canula 
and wind-pipe, which served the purpose of arresting the flow 
of blood into the air-passages, without causing irritation or 
spasm. Trendelenberg' s apparatus, it may be noted, is also 
provided with a cone, fltted to the end of a rubber tube, which 
is connected witli the cervical end of the tracheal canula. By 
this means the administration of the anaesthetic can be easily 
kept up at a distance from, and entirely out of the way of the 
operator. 

26 



402 ARTIFICIAL OPENINGS INTO THE AIPwPASSAGES. 



Sub-Hyoidean Phaeyngotomy. 

This operation was first performed in 1859, by a French sur- 
geon, Dr. Prat, for the removal of a large growth on the under 
surface of the epiglottis. The steps of the operation are as 
follows : a transverse incision about two and a half inches in 
length is made about a quarter of an inch above the upper 
border of the thyroid cartilage. The dissection is then carried 
through the superficial fascia, and the internal fibres of the 
platysma myoides, sterno-hyoid, and thyro-hyoid muscles, 
down to the thyro-hyoid membrane, which being cut through 
and the mucous membrane reached, an opening is made into 
the pharynx through the fold of membrane which forms the 
giosso-epiglottic ligament. The epiglottis is then seized and 
drawn out through the wound, when access to the cavity of 
the larynx will be obtained. 

This operation is mainly of value in those cases in which 
large growths or foreign bodies are so situated in the ujDper 
portion of the larynx, or in the pharynx, that they present in- 
superable obstacles to the endo-laryngeal operation. As will 
be easily perceived, these cases are necessarily very rare, hence 
it is not probable that the operation will be often resorted to. 



CHAPTER XXIV. 

EXTIEPATION OF THE LAEYNX. 

Malignaistt disease in the larynx is amenable only to three 
methods of removal ; by the endo-laryngeal method, by thy- 
rotomy, and by resection or extirpation of the organ. As al- 
ready stated, the endo-laryngeal method fails utterly in ac- 
complishing the object. In thyrotomy it would seem that we 
possess a means of reaching these growths by which they might 
be entirely eradicated ; unfortunately, however, clinical expe- 
rience teaches that almost invariably there is a recurrence of 
the disease sooner or later after the operation. In view of this 
fact, Czerny, in 1870, suggested the feasibility of the complete 
removal of the larynx, the suggestion being based on a series 
of experiments on the lower animals ; and in 1873 Billroth put 
in practice this daring procedure for the first time on the hu- 
man subject. The operation has been performed twenty-three 
times at the present writing, and the records of the cases, with 
their ultimate results, are so far before us that we may form 
some true estimate of its promise and justifiability. The pro- 
cedure is so novel, and to one's first impression, so hazardous, 
that surprise is excited that success should have attended the 
operation, even in the small proportion of cases in which such 
success has been reported ; or in fact, that so large a proportion 
of patients should have survived the removal of so important 
an organ. 

Perhaps a fairer estimate of the operation, and its proper 
place among surgical procedures will be attained by a brief ac- 
count of the reported cases : 

Case I. — The first operation was performed by Billroth on November 11, 1873, on 
a man aged fifty, suffering- from an epithelioma involving- the upper ring- of the trachea 
and the whole of the larynx. The tumor had so far occluded the air-passag-es that 
the trachea had been opened some months before Billroth performed his operation. 
The whole larynx and two rings of the trachea were removed. The immediate result 



404 EXTIRPATION OF THE LAEYNX. 

was successful and the patient was fitted with Gussenbauer's artificial vocal apparatus, 
by means of which he could converse in quite a distinct, though monotonous tone of 
voice. The disease recurred at the end of four months, and the patient died seven 
months after the operation. 

Case II. — The operation was done by Heine, on April 28, 1874, on a man, aged 
fifty, with a carcinoma of the larynx. The whole organ was removed successfully, 
and the patient survived six months, but finally succumbed to a recurrence of the 
disease. 

Case III. — The third extirpation of the larynx was done by Maas, of Breslau, 
June 1, 1874, who operated on a man, aged fifty-seven, suffering from an adeno- 
fibroma carcinomatosum. The whole larynx was removed, but the patient died on 
the fourteenth day, of pneumonia. 

Case IV.— Schmidt, of Frankfort, operated August 12, 1874, on a man, aged 
fifty-six, suffering from an epithelial carcinoma of the larynx. The whole of the 
organ was removed excepting the epiglottis, but the patient died on the fourth day. 

Case V. — Billroth, on November 11, 1874, performed his second operation. The 
patient was a man, aged fifty-four, who had suffered for a year from a carcinoma cf 
the larynx. At the time of the operation the mass almost entirely occluded the 
rima glottidis. He also manifested in a marked degree the cancerous cachexia. 
The whole larynx was removed, but the patient succumbed on the fourth day from 
broncho-pneumonia. 

Case VI. — Schonborn, of Konigsberg, operated, January 22, 1875, on a man, aged 
seventy-two, suffering from a carcinoma of the larjmx, removing the whole of the 
organ. The patient died on the fourth day from pneumonia, with gangrene of the 
lung. 

Case VII. — The most successful case yet recorded is that of Botlini, of Turin, 
who operated on a man, aged twenty-four, suffering from a sarcoma of the larynx. 
In spite of a very serious hemorrhage, and also an attack of erysipelas, which set 
in during the healing of the wound, the patient made a perfect recovery, and on 
November 26, 1878, was acting as a postman in Miazzina, and was in the enjoy- 
ment of the best of health. 

Case VIII. — Laugenbeck, on July 21, 1875, operated on a man, aged fifty-seven, 
suffering from a carcinoma, involving the whole larynx and extending to the base of 
the tongue. The operation is described as a " truly methodical and scientific surgi- 
cal masterwork, the extirpation being done as smoothly as an anatomical dissec- 
tion." The whole larynx, the hyoid bone, and portions of the tongue, pharynx, and 
• oesophagus were removed, together with a collection of diseased lymphatics in the 
submaxillary region. Forty-one vessels were ligated, among which were the exter- 
nal carotid, lingual, external maxillary, and superior thyroid arteries of each side. 
Each vessel was ligated before it was divided, and consequently the hemorrhage was 
comparatively slight. The patient made a good recovery, and enjoyed relatively 
good health. On November 12th the disease having recurred in the lymphatic 
glands of the neck, a second operation was performed for their removal, resulting in 
the death of the patient, from collapse, on November 23d, four months after the first 
operation. 

Case IX. — Maas performed his second operrtion on February 5, 1876, removing 
the whole larynx in a man, aged fifty years, suffering from an epithelial cancer. The 
patient made a good recovery, and was discharged wearing an artificial vocal appa- 
ratus. The disease recurred at the end of three months at the base of the tongue. 
Declining another operation, he died from hemorrhuge from the ulcerated surface 
six months after the first operation. 



EXTIRPATION OF THE LARYJS-X. 405 

Cape X.— Gerdes, of Jever, operated on March 30, 1876, on a man, aged seventy- 
six, suffering from an epithelial cancer. The whole larynx was removed, but death 
followed at the end of four days, from exhaustion. 

Case XL — Reyher, of Dorpat, in May, 1876, operated on a man, aged sixty, suf- 
fering from a diffuse carcinoma of the larynx. The whole organ was removed ex- 
cepting the epiglottis. The patient died on the eleventh day from catarrhal pneu- 
monia. 

Case XII. — Kosins';y, of Warsaw, operated March 15, 1877, on a woman, aged 
thirty-six, suffering from an epithelial cancer. The whole larynx was removed. 
The patient made an excellent recovery, and at the end of the seventh week was pre- 
sented to the medical society of Warsaw, wearing an artificial vocal apparatus, by 
means of which she conversed with comparative facility. The disease, however, re- 
curring, she died nine months after the operation. 

Case XIII. — Bottini, of Turin, on August 29, 1877, performed his second opera- 
tion on a man aged forty -eight, suffering from an epithelioma of the larynx. The 
whole larynx, with a portion of the anterior wall of the oesophagus, was removed. 
The galvano-cautery was used in this case, rendering the operation almost bloodless. 
The patient, however, died on the third day from pneumonia. 

Case XIV. — Foulis, of Glasgow, on September 10, 1877, removed the whole of 
the larynx, with the exception of a small part of the arytenoid cartilages, in a man 
aged twenty-eight, suffering from a sarcoma. The operation was entirely success- 
ful, the patient making a perfect recovery. The artificial larynx shown in Fig. 
175 was dev.sed for this case, and worn with comfort, the man being able to carry 
on conversation with ease. He occupied a position as telegraph clerk after the 
operation, but developing pulmonary disease, he succumbed to that affection on 
March 1, 1879, nearly eighteen months after the removal of the larynx. There was 
no return of ihe laryngeal disease. 

Case XV. — Wegner, of Berlin, operated, September 16, 1877, on a woman aged 
fifty-two, with a carcinoma of the larynx, the size of a walnut, springing from the 
right ventricle. The who'e larynx was removed with the exception of the epi- 
glottis. The woman made a perfect recovery, and on April 12, 1878, she was pre- 
sented at the Seventh Annual Congress of German Surgeons, wearing an artificial 
larynx by means of which she conversed with ease and facility. 

Case XVI. — The elder Von Bruns, of Tubingen, on January 29, 1878, removed 
the whole larynx in a man aged fifty-four, suffering from an epithelial cancer. This 
patient made a good recovery, but finally succumbed to a recurrence of the disease, 
nine months after the operation. 

Cask XVII. — Rubio, on May 11, 1878, operated on a man aged forty-one, suffer- 
ing from perichondritis of the laryngeal cartilages resulting in necrosis. The whole 
larynx was removed, The patient died on the fifth day from collapse. 

Case XVIII. — Billroth performed his third operation on July 7, 1878, on a man 
aged fifty, suffering from nn epithelial cancer involving the left side of the larynx. 
The diseased half of the organ was removed and the patient made an apparently 
excellent recovery, Vjut there was subsequently a recurrence of the disease, under 
which he succumbed ten months after the operation. 

Case XIX. — Czerny, on Augu.^t 24, 1878, operated on a man aged forty-six, suf- 
fering from a round-cell sarcoma, the size of a walnut, attached to the right ven- 
tricular band. The tumor so far occluded the laryngeal cavity that tracheotomy 
had been performed. The whole larynx was removed and the man made an excel- 
lent recovery. This patient was quite well at a recent date, and wearing an arti- 
ficial larynx which enabled him to converse with facility and distinctness. 



406 EXTIKPATIO:^ OF THE LARYNX. 

Case XX.— Billroth performed his fourth operation on February 27, 1879, on a 
woman aged forty-three, suffering- from an epithelioma of the pharynx and larynx. 
The whole organ was removed with portions of the pharynx and oesophagus. She 
made a good recovery, but died at the end of six weeks, from the passage of a 
bougie into the mediastinum, which was being introduced into the oesophagus. 

Case XXI. — Caselli, of Reggio-Emilia, operated, September 29, 1879, on a young 
girl aged nineteen, who had for a year suffered from a progressive "lymphatic 
granuloma," involving the fauces and larynx, which had become so exquisitely pain- 
ful, and so far interfered with deglutition and respiration as to render the operation 
imperative. The whole larynx was removed, together with the soft palate, tonsils, 
base of the tongue, pharynx, and oesophagus, down to a point opposite the fifth cer- 
vical vertebra. The operation was done with the galvano-cautery, a previous tra- 
cheotomy having been performed, and consumed three hours and ten minutes. But 
few vessels required ligation, and the loss of blood was trifling. A modification of 
Gussenbauer's artificial vocal apparatus was subsequently introduced, and at present 
writing the patient is doing well and converses with facility. 

Case XXII. — Dr. Lange, of New York, performed the first extirpation of the 
larynx done in America, on October 12, 1879. The patient was a man aged seventy- 
four, who had suffered for over a year from what was discovered to be a mixed 
round and spindle-celled sarcoma, apparent! 3' springing from the right ventricle. 
The tumor had developed so rapidly that tracheotomy had become necessary eight 
months previously. The whole larynx, with a portion of the anterior wall of the 
oesophagus, was removed, and a month later an artificial larynx was inserted. The 
case seemed to progress favorably for four months, but from that time the adminis- 
tration of nourishment became difficult, on account of the sinking in of the oesoph- 
agus and trachea, and the patient succumbed on May 2, 1880. The immediate 
cause of death was asthenia, although a few weeks previously there had developed 
a return of the disease. At the time of death, the oesophagus and trachea had sunk 
one and a half inches below the sternum. 

Case XXIIL— Dr. Gerster, of New Y^ork, on March 5, 1880, operated on a man 
aged fifty, for a sarcoma involving the right side of the larynx, which had been 
growing for over a year, and which had rendered tracheotomy necessary six weeks 
previously. The right half of the thyroid, the whole of the arytenoid, the whole of 
the epiglottis, a portion of the base of the tongue, together with the right side of 
the pharynx, including the tonsil, were removed. The patient made an excellent 
recovery, and at present writing is doing well. 

We thus find tliat tlie operation lias been done, in all, 
twenty-three times, and that of these, sixteen were for carci- 
noma of the larynx, five for sarcoma, one for perichondritis 
with necrosis of the laryngeal cartilages, and one for a lym- 
phatic granuloma. Of the sixteen cases of carcinoma, seven 
died, as the result of the operation, one (Case XX.) died at 
the end of six weeks, from an accident, seven succumbed to a 
recurrence of the original disease, at periods varying from four 
to ten months after the operation, while in one case only (Case 
XV.) was the operation really successful. In other words, 
with this single exception, every patient suffering from malig- 



EXTIEPATION OF THE LARYNX. 407 

nant disease of the laiynx, who survived the operation a suffi- 
cient length of time, succumbed, sooner or later, to a recur- 
rence of the disease ; and, furthermore, the longest time to 
which the fatal issue was deferred, was ten months. In the 
one case in which the operation succeeded (Case XV.), the 
tumor was small and was confined to one side of the laryngeal 
cavity. 

Turning now to the remaining seven cases, we find that the 
operation was done in five cases for sarcoma, in one (Case XXL) 
for a "Ijmiphatic granuloma," and in one (Case XYII.) for 
perichondritis and necrosis of the huyngeal cartilages. This 
latter patient died, as the result of the operation. One case 
(Case XXII.) of sarcoma died from asthenia, seven months 
after the operation, while the remaining four cases of sarcoma 
and the one case of granuloma were entirely successful. We 
thus see that of these seven cases of extirpation of the larynx 
for non-malignant disease, five were successful, the original 
disease seeming to have been entirely eradicated. In Foulis' 
case (Case XIY.) it is to be remembered that although the 
patient died eighteen months after the operation, his death 
was due to pulmonary disease, and not to any recurrence of 
the laryngeal affection. 

The conclusions which may be drawn from this analysis, it 
seems to me, are very plain as regards laryngeal cancer, unless 
the future of this operation shall show an entirely different 
series of results. If the object in view be the eradication of 
the disease, we must regard it as, to a great extent, a failure, 
for a percentage of cures of one case in sixteen does not war- 
rant the resort to an operation of so serious a nature. If the 
object be the prolongation of life, it would seem an open ques- 
tion whether this has been accomplished, when the longest 
term of life secured has been but ten months ; bearing in mind 
also the success which often attends our improved means of 
topical applications in even so serious an affection as carci- 
noma of tlie larynx. 

It should be said, however, that in the very large propor- 
tion of these cases the operation was done as almost a last 
resort for the relief of urgent symptoms. In the single case of 
successful removal of a cancerous larynx, the tumor was small 
and the operation was done early in its development. The 
suggestion from this fact should not be overlooked ; that in 



408 EXTIRPATIOlSr OF THE LARYNX. 

the late stages of malignant disease of the larynx the radical 
operation is almost hopeless ; in its early stages there is such 
fair promise of success as to warrant the attempt. It is our 
last resort, and it failing, we are helpless to cope with this 
terrible disease. Confining our attention, however, to those 
cases in which the operation was done for the removal of non- 
malignant tumors, the success of the procedure has been most 
brilliant, and the operation has been well designated as "one 
of the greatest triumphs of modern surgery." Of the seven 
cases there were five cures, one death from the operation, and 
one death seven months later, from an indirect result of the 
operation. 

The Operation". — As regards the operation itself, it should 
be looked upon as an extremely difficult and intricate proced- 
ure rather than an essentially hazardous one ; and, moreover, 
one in which hidden dangers, and unforeseen accidents or ob- 
stacles are liable to present at any time. 

In general the method of operating is as follows : an in- 
cision is made from the hyoid bone to the sternal notch, and 
the larynx and trachea exposed partially by dissection, and in 
part by crowding the tissues to the side with the finger and 
handle of the scalpel. The trachea is then separated from its 
attachments, lifted and cut through. A Trendelenberg canula 
(Fig. 172), or some similar device is inserted into the open tra- 
chea, by means of which the anaesthetic is administered and the 
subsequent steps proceeded with. These consist in severing 
the further attachments of the larynx, exercising extreme care 
to avoid button-holing the oesophagus, and carrying the dissec- 
tion as far as the disease maybe found to extend. In Caselli's 
case (Case XXI.) the base of the tongue, soft palate, and ton- 
sils were involved, and hence their attachments were severed 
by operating through the mouth, a gag being inserted between 
the teeth. In Langenbeck's case (Case VIII.), portions of the 
CBsophagus, the hyoid bone, the base of the tongue, and a por- 
tion of the pharynx were removed, the operation requiring forty- 
one ligatures. This simply illustrates how the operation may 
be comparativel}^ simple in one case, while in another it may 
be an extremely intricate and complicated one. 

The Artificial Vocal Apparatus. — In the course of five 
or six weeks after the removal of the larynx, the parts will, as 
a rule, so far have healed as to tolerate the presence of an artifi- 



EXTIRPATION OF THE LARYNX. 



409 



cial larynx, by means of which a nsefiil though entirely mo- 
notonous voice will be afforded, and by which the patient will 




Fig. 173. 



Fig. 174. 



Fig. 173. — Gussenbauer's artificial vocal apparatus : ?', tracheal tube ; Z, oral tube ; ni, cervical plate ; 
n, catch for holding reed-plate in position ; c, artificial epiglottis. 

Fig. 174. — G-ussenbauei's artiticial vocal apparatus in section : ?i, tracheal tube; o, oral tube; c, arti- 
ficial epiglottis ; d, reed-plate. 

be enabled to carry on conversation with comparative facility. 
The first instrument of this character which was devised was 
that of Gussenbauer, Figs. 173, 
174, This instrument consists of 
an ordinary double tracheal can- 
ula (Fig. 173, i), on the upper side 
of which is an oval fenestrum 
through which there is passed a 
tube (Fig. 173, 1,) similar in shape 
to the tracheal tube, but passing 
upward toward the oral cavity. 
At the upper extremity of the 
tube there is filled a movable cap 
(c), which acts as an artificial epi- 
glottis, preventing the entrance 
of mucus and particles of food 
into the air-passages. In this 
manner 'there is really nothing 
more accomplished than the es- 
tablishment of a channel of com- 
munication between the lungs 
and mouth, the upper end of 
which is protected by the arti- 
ficial epiglottis, and which has 
also an external opening upon the neck. The apparatus is 
completed by the insertion into the cervical opening of a plate 




Fig. 175.-Fou1Ir' modiflciti 
baiier'8 artificial vocal apimintuh I llu 
tube; /*, the lower or tiathml tub ( 1 
cal reed. (Mackenzie) 



410 EXTIRPATION OF THE LAEYNX. 

containing a reed (Fig. 174, d.) Tins is held in place by a catch 
(Fig. 173, n). The cervical end of the reed-plate is cylindrical 
and lills the calibre of the opening into which it is inserted. 

The outgoing current of air from the lungs thus passes into 
the oral cavity, being thrown into monotonous vibrations by the 
reed, and these are formed into articulate language by the 
tongue, soft palate, etc. In this apparatus the lower tube is 
first inserted, but the subsequent introduction of the upper 
tube seems to be attended with such difficulty that Foulis de- 
vised an arrangement by which the upper tube is first placed in 
position, after which the tracheal tube is passed through its 
lower extremity. This device is shown in Fig. 175. As in the 
Gussenbauer apparatus, the reed is passed into the cervical 
opening in a separate plate which fits into grooves on the sides 
of the canula. 

These devices are described as illustrative of the general 
principles on which the artificial vocal apparatus is constructed. 
In each case in which the device has been made use of, modifi- 
cations have been rendered necessary by the varying require- 
ments of the individual patient, and the extent to which the 
parts had been removed. 



APPENDIX, 



There is given below a number of formulae of such reme- 
dies as I have found of value, as topical agents in the treat- 
ment of the various affections of the upper air-passages. The 
list is not a large one, as I do not regard the selection of any 
special remedy as of so much importance as the thoroughness 
with which it is applied to the part. There is also added a 
number of formulae for cough mixtures, in use at the Bellevue 
Throat Clinic. 

Aqueous Solutions. 

Cleansing Solutions. 

In all forms of catarrhal, follicular, and ulcerative diseases 
of mucous membranes, the first essential in topical treatment is 
the thorough cleansing of the diseased surface preparatory to 
the application especially indicated. These may be applied 
by means of the douche, post-nasal syringe, or the atomizer. 

(DOBELL.) 

]J . Acidi carbolici gr. j. 

Soda3 biborat., 

Sod^c bicarb aa gr. ij. 

Glj^cerinse 3 j. 

Aquae ad. 3 j. 

M. 



^ . Acidi carbolici s;y. j 

Sodii chloridi gr. i 

Aqufe 3 ]'• 

M. 



412 APPENDIX. 

B ' Acidi salicylici gi". j. 

Sodge bicarb gr. i\^. 

Aqnse 3 j. 

M. 

I^ . Potassge bicarb gr. iv. 

Aquffi I j. 

M. 

I^ . Aquae calcis, 

Aqnse aa 5 j. 

M. 

5- . Potassse bicarbonatis gr. iv. 

Potassse cliloratis gr, ij. 

Aqu^ie 3 j. 

M. 

I^ . Sodfc phospliatis gi'- v. 

Aqua3 ! j. 

M. 

IJ . Ammonii mur gr. iv. 

Aquae 3J. 

M. 

5 . Acidi carbolici gr. ij. 

Glycerinae 3 j. 

Aquse ad. 3 j. 

M. 

Astringent Solutions. 

By an astringent is meant any remedy wliicli wlien locally 
applied to a mucous membrane lias the effect to control the 
excess of discharge, and at the same 'time diminish the abnor- 
mal blood-supply by its direct constringent action on the ves- 
sels. These may be applied by means of the sj^ringe, douche, 
atomizer, sponge, or brush. My preference is decidedly in 
favor of the atomizer, as depositing the agent on the diseased 
surface in a manner which is the least irritatino; of all methods. 



APPENDIX. 413 

At tlie head of the list of these agents is placed nitrate of 
silver. We possess no remedy which is so valuable for its 
astringent action, but the serious mistake which is made, is in 
applying it in solutions of too great strength.. It should never 
be used in a stronger solution than gr. xx. — 3]*., and rarely 
stronger than gr. x. — 3 J. It possesses a somewhat stimulating 
action, which contraindicates its use in acute catarrhal inflam- 
mations. Its especial value is in chronic inflammatory affec- 
tions, and may be used both in simple catarrhal and follicular 
disease of the membrane. It possesses alterative and resolvent 
properties which render it useful in the latter form of disease. 

Argenti nitrat gr. ij, — xx. to | j. 

Zinci sulphatis gr. v. — xv. to 3 j. 

Ferri et aluminis sulph gr. v. — x. to I J. 

Acidi tannici gr. x. — xx. to 3 j. 

Zinci chloridi gr. v. — x. to 3 j. 

Potassse chloratis gr. x. — xx. to | j. 

Alum. gr. V. — x. to § j. 

Glycerinae tannat 3 ss. — 3 j. to § j. 

Cupri sulphat gr. iij. — x. to 3 j. 

Ferri sulphat gr. ij.— v. to 3 j. 

Stimulating Solutions. 

By this is meant a remedy which, when applied to the sur- 
face of a mucous membrane, excites for the time an excessive 
discharge of thin mucus or sero-mucus. When this subsides, 
the membrane is left in a state of healthier functional activity. 
These agents are indicated in atrophic or dry catarrh, whether 
of the pharynx or nasal cavities. 

Tinct. sanguinaria 3 ss. — 3 j. to 33. 

Tinct. iodini tjI ij.— x. to 3 j. 

Potass, iodidi gr. iij.— x. to 3 j. 

Potass, bromidi gr. x.— xx. to 3 j- 

Infus. picis liquid^c 3 j. — 3 iij. to 3 j. 

Vini ipecac 3 ss.— 3 j. to | j. 

Tinct. belladonnje 3 ss.— 3 j. to 1 j. 

Ammonii chloridi gr. v. — x. to 3 j. 

Acidi carbolici gr. x.— xx. to § j 

Creasoti m iij-— vi. to 3 j 



414 APPENDIX. 

Sedative Solutions. 

These are for use in connection with the preceding stimu- 
lating or astringent remedies, or following them in case their 
application gives rise to pain or irritation. Sedatives are espe- 
cially indicated also in acute affections, as exerting a direct 
controlling influence on the morbid process. 

Morphia sulphat gr. v. — xx. to § j. 

Aq. ext. opii gr. x. — xl. to 3 ]'• 

Ext. hyoscyami gr. x. — xl. to 3 j. 

Ext. belladonnse gr. ij.— vi. to 3 j. 

Acidi hydrocyanici dil '^ ij. — x. to 3 j. 

Infus. lupulini q. s. 

Decocti papaveris q. s. 

Aquge laurocerasi q. s. 

Aquse amygdalae amar^ q. s. 

Alterative and Resolvent Solutions. 

These are certain remedies which act locally to produce ab- 
sorption of the results of a chronic morbid process, which has 
led to the deposit in the deep layers of the mucous membrane, 
or in the follicular walls, of neoplastic tissue, provided the new 
deposit has not become too firmly organized. 

Argenti nitratis gr. j. — iij. to 3 3. 

Zinci chloridi gr. ij. — iv. to 3 j. 

Hydrarg. chloridi corrosivi gr. j. — ij. to 3 j. 

Ammonii chloridi gr. v. — x. to I j. 

Liq. potassffi arsenitis iri ij.— x. to 3 j. 

Tinct. iodi. co m iij.— x. to 3 j- 

D Is i nfecta nt So lu tions. 

These are intended for use in cases of nasal catarrh attended 
by fetid or offensive discharges. They are also of value in 
ulcerative action in the fauces, or in any affection attended 
with fetor. 

Carhollc add is a remedy of varied usefnlness as a topical 
agent. Its action, in the milder strength of gr. j.— 3 j., is as a 



APPENDIX. 415 

cleansing and disinfectant agent ; in the strength of gv. x. — 
XX. to I J., it is a decided stimulant ; in the still stronger solu- 
tion of 3 ij. — 3 j. to I J., it is an escharotic. Its a&e, therefore, 
is as an aid to other remedies, in cleansing or disinfecting a 
diseased membrane preparatory for the more especially indi- 
cated remedy. It is of very doubtful value as a topical appli- 
cation in any acute form of inflammation. It should be placed 
among the most valuable of disinfectants. Other drugs may 
be noted, as follows : 

Potass, permanganat gr. x. — 3 ss. to 3 j. 

Acidi salicylic! gr. ij. — iv. to 3 j. 

Sodse salicylatis gr. v. — x. to | j. 

Liq. sodse chlorinatJB 3 ss. — 3 j. to 3 J. 

Acidi acetic "ni x. — xv. to 3 J. 

Acidi sulphurosi tt], iij. — v. to 3 J. 

Zinci sulpho-carbolat gr. j. — iiJ. to 3 j 

POWDEES OK SnIJFFS. 

The action of a powder or snuff on a mucous membrane dif- 
fers from an aqueous solution only in that it is to an extent 
more permanent and more prolonged. On the other hand, it 
is not so evenly diffused, nor does it probably reach the parts 
so thoroughly, especially in the tortuous passages of the nose. 
In the preparation of a snuff there is substituted for the water, 
in the aqueous solutions already given, a light neutral powder, 
in which the astringent, sedative, or stimulating agent may be 
incorporated in the same proportion as that given. A powder, 
when applied to a mucous membrane, is dissolved in its mucus, 
and in this state of solution is absorbed, and thus produces its 
intended effect. Any of the aqueous solutions already given 
may be administered, therefore, in the form of a snuff, by sub- 
stituting for the water lycopodium, pulv. amyli, pulv. acacias, 
sacch. alb., magnesise carb., or any other neutral powder. In 
addition, there are given a few formulae, which have been 
found efficient. 

AstTlnrjent Poioders. 

It.... 
Bismuth, subcarb 



M. 



416 APPENDIX. 

5 . Hydrastin gr. x.— 3 ss. 

Lycopodii 3 ss. 

M. 

3 . Hj^drastiu 3 ss. 

Piilv. campliorse gr. x. 

Piilv. acaciffi ad. 3 j. 

M. 

3.. Lupulin 3 j. 

Bismuth, subcarb 3 vij. 

M. 

Stinndatlng Powders. 

Vp . Pulv. galangae 3 ij._ s ss. 

Pulv. amyli ad. 3 j. 

M. 

IJ. Pulv. sanguinaricB 3 ij. — 3 ss. 

Lvcopodii ad. 3 j. 

M. 

I^ . Pulv. belladonna 3 j. — 3 ij. 

Pulv. acaciffi ; ad. 3 j. 

M. 

5 • Pulv. uijaTlup 3 j. — 3 iij. 

Pulv. am3'li ad. 3 j. 

M. 

Alteratli^e Powders. 

5 . lodoformi 3 vi. 

Lycopodii 3 ij. 

I^ . lodoformi 3 j. — 3 ij. 

Pulv. camphors 3 j. 

Pulv. am^'li ad. 3 j. 

M. 

B- Hydrarg. cliloridi mitis 3 ss. — 3 j. 

Saccli. alb ad. 3 j. 

M. 



APPENDIX. 417 

^ . Hydrarg. rubri oxidi, 

Hydrarg. cliloridi mitis aa 3 ss. 

Sacch. alb ad. | ss. 

M. 

Inhalations. 

The essential difference between an inhalation and the ap- 
plication of an atomized fluid lies in the fact, tliat in the one 
case the agent is carried into the air-passages by the act of in- 
spiration, and thereby reaches not only the larynx, but also the 
trachea and even the bronchi ; whereas, in applying a remedj^ 
by means of the atomizer it does not, as a rule, reach farther 
than the vocal cords, as the rima glottidis is usually closed 
during the manipulation of applying the spray. ^ In those cases 
of laryngeal disease attended with cough and irritation of the 
air-passages inhalations are of especial value. In these cases 
the trachea and probably the larger bronchi are involved in 
the morbid action, and are reached and acted upon by reme- 
dies used in this manner. 

Inhalations may be used by an}^ of the different forms of 
spray-producers. It is an excellent plan to allow the atomizer 
to play in a large glass globe to the open mouth of which the 
patient applies his mouth. In this manner the finer particles of 
the fluid are carried into the trachea and bronchi. Any of the 
remedies given under the head of aqueous solutions may be 
used in this manner according to the indications. In chronic 
inflammatory affections, cold inhalations only should be given. 
In acute affections the fluids used may be atomized by the 
steam atomizer shown in Fig. 66. Another form of inhalation 
consists in inhaling the active jDiinciples of certain drugs which 
have been volatilized by heat. For this purpose the inhaler 
shown in Fig. 67 may be used, or a simple cup or open mouth 
bottle. In the remedies given below a teaspoonf ul of the mix- 
ture is to be placed in the cup and a pint of hot water poured 
upon it, and the patient directed to inhale the vapor as long- 
as it is given off. In this manner there may be used the fol- 
lowing, their action being first slightly stimulating, but this is 
followed by a sedative effect. 

IJ . Creasoti 3 j. 

Tinct. benzoini co 3 j- 

M. 

27 



418 APPENDIX. 

01. resin lupuliii q. s . 

Tinct. opii campli q. s. 

Tinct. opii q. s. 

Creasoti 3 ij. — § j. 

Acidi carbolici 3 ij. — = j. 

01. copaibpe z ij. — 3 j. 

01. cubebse 3 ij. — 3 j. 

01. terebintli 3 ij. — 3 j. 

Tinct. iodini 3 j. — 3 j. 

01. pini Sj^vestris tti xl. — 3 j. 

In these latter the agent is to be diluted with alcohol, as 
above. 

Cough Mixtures. 

The propriety of administering a cough mixture in all cases 
of mere throat disease, to allay a slight cougli or irritability 
which may exist, is somewhat doubtful; and yet it will in 
many cases become necessary. 

It is a very ancient usage to administer remedies for the 
alleviation of a cough in a syrup — indeed, the terms cough mix- 
ture and cough sja-up are synonymous. This ]3ractice should 
be avoided. S3a'ups are very liable to produce disorder of the 
stomach, hence, when we remember the intimate sympathy ex- 
isting between the stomach and the throat, it is easy to under- 
stand how a cough syrup administered to relieve a cough at- 
tendant upon a throat catarrh, may serve to aggravate rather 
than alleviate the disease. 

I^ . Codeia3 gi'- i.1- 

Acidi hj^drocyanici dil 3 ss. 

Tinct. tolutani 3 vi. 

Aquffi ad. 3 iv. 

M. Sig. — One teaspoouful tliree or four times daily. 

J^ . Potass, bromidi ^ ss. 

Potass, cyanidi gr. iv. 

Fl. ext. prun. virginiani 3 vi. 

Aquse ad. 3 iv. 

M. Sig. — As above. 



APPEN^DIX. 419 

j^ . Codeige gr. iij. 

Potass, cyanidi gr. iv. 

Tinct. tolLitani 3 j. 

Aquae ad. § iv. 

M. Sig. — Same as above. 

^ . Ammonia carb gr. xx. 

Tinct. opii campli 3 iij. 

Tinct. scillse 3 ij. 

Inf usi senegse ad, § iv. 

M. Sig. — Same as above. 

P^ . Pulv. cubebse. 3 ijss. 

Tinct. tolntani, 

Mucil. acacise aa 3 j. 

Muse , ^ij. 

M. Sig. — Same as above. 

15 . Fl. ext. cubebse 3 iij. 

Gljcerin^e 3 iss. 

Aquse ,., ad. 3 iv. 

M. Sig. — Same as above. 

Fp . Mur. ammonia 3 ijss. 

Tinct. tolntani, 

Tinct. sanguinaria aa 3 j. 

Aquse 3 ij. 

M. Sig. — Same as above. 

?. Acidi liydrocyanici dil., 

Cliloroformi aa 3 ss. 

Tinct. liyoscyami, 

Tinct. tolutani, 

Aquse campliorse, 

Mucil. acacise , Ji^^ • 3 j- 

M. Sig. — Same as above. 

]J . Ammonia carbonat 3 iij. 

Spts. ether co 3 j. 

Fl. ext. cubebse 3 v. 

Aq. amygdala amame ad. 3 iv. 

M. Sig. — Same as above. 



420 APPEXDIX. 

^ . Antimonii et potassse tartrat gi'- ij- 

Tinct. scillse, 

Tiiict. sangninarise aa § j. 

Aquae ad. | iv. 

M. Sig. — Same as above. 

^. Potass, nitratis • 3 ij. 

Tinct. scillse 3 y. 

Tinct. digitalis 3 j. 

Mucil. acacise | j. 

Aquse ad. 3 iv. 

M. Sig. — Same as above. 

]J . Acidi hydrobromici dil § j. 

Spts. cliloroformi 3 j. 

Tinct. scillse 3 ss. 

Aquae ad. 3 iv. 

M. Sig. — Same as above. 

I^ . Potass, clilorat 3 j. 

Ext. giycyrrhizffi 3 iijss. 

Ammonii cliloridi 3 j. 

Aquee ad. 3 iv. 

M. Sig. — Same as above. 

IJ . Tinct. tolntani § ss. 

Acidi acetici 3 iij. 

Tinct. sanguinarise 3 vi. 

Fl. ext. prun. virginiani f ss. 

Aquae ad. 1 iv. 

M. Sig. — Same as above. 



INDEX 



Abductors, bilateral paralysis of the, 348 
Abortion of a cold, 176 
Accessory sinuses the source of ozgena, 227 
Acetic acid in hypertrophic nasal catarrh, 

199 
Aconite, in acute tonsillitis, 116 

in subacute laryngitis, 266 
Actual cautery, in chronic follicular pha- 
ryngitis, 104 
in enlarged blood-vessels in pharyn- 
geal catarrh, 88 
in hypertrophic nasal catarrh, 201 
Adams' operation for a deviated septum, 

249 
Alterative powders, 416 

solutions, 414 
Ammonia, in chronic laryngitis of syphilis, 
304 
in chronic pharyngitis, 105 
in subacute laryngitis, 263 
Anaemia resulting from enlarged tonsils, 

133 / 

Anaesthetics in tracheotomy, 394 
Ansesthesia of the larynx, a symptom not 
a disease, 328 
local, for operating, 377 
Angiomata of the larynx, 368 
Anodynes, the local action of, in laryngeal 
afEections, 305 
the local use of, in laryngeal phthisis, 
294 
Anosmia, 251 
Antrum of Highmore, 167 
Aphonia, functional, 344 
hysterical, 344 
in subacute laryngitis, 2G1 
Appendix, 411 
Arytenoid cartilages, 253 

thickened in lirst stage of laryngeal 
phthisis, 288 
Arytenoideus muscle, 256 

paralysis of, 340 
Astringent powders. 415 

solutions, 412 
Atomization, the use of compressed air in, 

58 
Atrophic catarrh of the nares, 213 
of the pharynx, 89 



Belladonna in subacute laryngitis, 266 

Bellocq's canula, in tying the palate, 29 
method of using, 247 

Bergson's principle of atomization, 56 

Billroth, case of extirpation of the larynx, 
403 
second case of extirpation of the la- 
rynx, 404 
third case of extirpation of the larynx, 
405 

Blake, case of paralysis of the abductors, 
356 

Blandin's punch for deviation of the sep- 
tum, 250 

Bloodletting in acute tonsillitis, 115 

Borde, Dr. A., case of paralysis of the ab- 
ductors, 353 

Bottini, case of extirpation of the larynx, 
404 
second case of extirpation of the la- 
rynx, 405 

Bright's disease a cause of oedema glotti- 
dis, 279 

Brouge, operation for fibroma of nares, 
244 

Brush, the use of in naaking applications, 
49 

Buck's laryngeal scarifier, 282 

Burow, case of paralysis of the abductors, 
356 



Cadaveric position of the vocal cords, 333 

simulated in hysterical aphonia, 346 
Cancer of larynx, 379 

Carcinoma of larynx, differential diagnosis 
from syphilis, 314 
justifiability of extirpation of the la- 
rynx in, 407 
Caselli, case of extirpation of the larynx, 

406 
Catarrh, atrophic, essential morbid condi- 
tion in, 89 
atrophy of the turbinated bones in, 

221 
chronic nasal, 178 
dry, of nares, 212 
dry, of pharynx, 89 



422 



INDEX. 



Catarrh, fetid nasal, 219 
hypertrophic nasal, 184 
method of development of fetor in the 
nares, 220 
Cautery, the actual, in chronic follicular 
pharyngitis, 104 
in enlarged blood-vessels in chronic 
pharyngitis, 88 
Chorditis tuberosa, 368 
Chromic acid in hypertrophic nasal ca- 
tarrh, 198 
Cicatrices in the larynx from deep ulcers 
in syphilis, 312 
in the phai-j'nx from deep syphilitic 
ulcers, 151 
Cleansing solutions, 411 
Cohen, case of paralysis of the abductors, 
355 
chloroform in acute coryza, 176 
syphon douche, 53 
Cold in the head, 173 
Coryza, acute, 173 
chronic, 180 
syphilitic, 231 
Cotton pledget, the use of in making ap- 
plications, 49 
Cough mixtures, 418 

useless in pharyngitis, 105 
Crico-arytenoid muscles, 255 

laterales muscles, bilateral paralysis 

of, 337 
lateralis muscle, unilateral paralysis 

of, 337 
postici muscles, bilateral paralysis of, 

348 
posticus muscle, unilateral paralysis 
of, 335 
Crico-thyroid muscles, 255 
Croupous pharyngitis, differential diag- 
nosis from diphtheria, 109 
Cubebs, in chronic ijharyngitis, 105 

in subacute laryngitis, 263 
Cusco's laryngeal forceps, 372 
Cystic tumor of the larynx, 367 
Czerny. case of extirpation of the larynx, 
405 



Deglutition, difficult, in deep ulcers of the 
larynx in syphilis, 313 
movement of the larynx in, 258 
painful, in laryngeal phthisis, 291 

Dentition a cause of enlarged tonsils, 127 

Deviation of the septum narium, 248 

Diptheria, differential diagnosis from 
croupous pharyngitis, 109 

Disinfectant solutions, 414 

Dobell's solution, 411 

Donaldson, the use of chromic acid in en- 
larged tonsils, 136 

Douche, the post-nasal, 51 
the Weber nasal. 53 

Duncan, method of tj'ing the palate by 
catheter, 29 



Duplay's rhinoscope, 28 

Dupuytren, on pigeon-breast in enlarged 

tonsils, 132 
Durham's tracheal canula, 389 
Dyspepsia, the influence of, on chronic 

pharyngitis, 84 



Ecraseur, Mackenzie's guarded wheel, 376 
Electricity, treatment of laryngeal paral- 
ysis by, 342 
Elongated uvula, method of removing, 96 
Elsberg's improved fponge-holder, 51 

nasal speculum, 24 

spring-forceps sponge-holder, 50 

uvulatome, 95 
Epiglottis, the, 254 

the varying shapes of, 15 

turban-shaped, in laryngeal phthisis, 
290 
Epistaxis, 245 
Extirpation of the larynx, 403 

method of operation, 408 



Fahnestock's tonsillotome, 139 
FauveFs laryngeal forceps, 371 

modification of Mackenzie's laryngeal 
electrode, 343 
Feith, case of paralysis of the abductors, 

354 
Fibromatq, of the larynx, 367 

of the nares, 243 
Fomentations, useless in subacute tonsil- 
litis, 122 
Forceps, Cusco's laryngeal, 372 
Fauvel's laryngeal, 371 
Mackenzie's laryngeal, 372 
Mackenzie's tube, for larynx, 374 
Stoerck's laryngeal, 375 
Tobold's laryngeal, 371 
Foulis, case of extirpation of the larynx, 
405 
modification of Gussenbauer artificial 
vocal apparatus, 409 
Fraenkel's nasal speculum, 23 
Frontal sinuses, 167 



Galanga. in dry catan-h of the nares, 216 
use in dry catarrh of the pharynx, 92 
Galvano-cautery in hypertrophic nasal ca- 
tarrh, 201 
Gargling, proper method of, 80 
Gelatinous polypus in the nares, 238 
evulsion by the forceps, 240 
removal by the snare, 242 
Gendron's bivalve tracheal canula, 391 
Gerdes, case of extirpation of the larynx, 

405 
Gerster, case of extirpation of the larynx, 

406 
Glynn, case of paralysis of the abductors, 
357 



INDEX. 



423 



Groodwillie's nasal speculum, 23 

the use of the dental engine in necro- 
sis of the nasal bones, 237 

Guersant, on hemorrhage from excision of 
the tonsils, 137 

Gruaiac in acute tonsillitis, 118 

Gummata, a source of the deep ulcers of 
laryngeal syphilis, oil 

Gussenbauer's artificial vocal apparatus, 
409 

Hemorrhage in tracheotomy, 395 
Hager's remedy for an acute coryza, 177 
Hamilton's tonsillotome, 140 
Hartewelt's laryngeal syringe, 52 
Ha ward. Dr., explanation of nightmare 

in enlarged tonsils, 131 
Hays, case of paralj^sis of the abductors. 

358 
Head-mirror, Pomeroy's, 3 
Schroetter's, 2 
spectacle frame, 4 
the author's, 3 
Heart disease a cause of oedema glottidis, 

279 
Heart, hypertrophy of, in enlarged tonsils, 

133 I 

Heine, case of extirpation of the larynx, 

404 ; 

Herpes of the pharynx, 162 j 

Howard's improvised tracheal canula, 393 
Hutchinson's tracheal dilators, 388 
Hypertesthesia of the larynx, a symptom 

not a disease, 328 
Hyperinosis in acute follicular tonsillitis, 

123 I 

in croupous pharyngitis, 107 [ 

Hyperplastic enlargement of the tonsils, i 

128 I 

Hypertrophic enlargement of the tonsils, 

129 
Hysterical aphonia, 344 
Hystero-neuroses of the fauces, 164 

Inflammation, catarrhal, 39 
croupous, 41 
diphtheritic, 42 
Inhalation, 02 
Inhalations, formulae, 417 

in subacute laryngitis, 266 
of steam, in acute laryngitis, 270 
of steam, in oedema glottidis, 283 
useless in laryngeal phthisis, 295 
Insufflator for self -use, 177 
Intemperance, its influence on chronic 

pharyngitis, 84 
Iodide of potassium in syphilis of the nose, 
235 
in the chronic laryngitis of syphilis, 

304 
in the deep ulcers of laryngeal syphi- 
lis, 315 



Iodide of potassium in the deep ulcers of 

syphilis in the pharynx, 150 
Iodoform, in laryngeal phthisis, 294 

in syphilitic ulcers of the pharynx, 

148 
in the deep ulcers of laryngeal syphi- 
lis, 316 
Iron, tincture of, in acute follicular ton- 
sillitis, 125 



Jackson, case of paralysis of the abduc- 
tors, 358 
Jarvis, Dr. W. C. case of hypertrophy of 

turbinated bones, jjosteriorly, 2U6 
Jarvis' wire snare ecraseur, 205 

use of, in hypertrophic nasal catarrh, 

206 
in removal of nasal polypi, 242 
transfixion i\eedle in anterior hyper- 
trophy of turbinated bones, 2(j6 
Juraz, case of paralysis of the abductors, 
358 



Kosinsky, case of extirpation of the larynx, 
405 

Knapp, danger of using the nasal douche, 
54 

Knight, cases of paralysis of the abduc- 
tors, 357 



La Borde's tracheal dilators, 387 
Lachrymal duct, 167 
Lancet powder in acute coryza, 176 
Lange, case of extirpation of the larynx, 
406 
use of punk to prevent the entrance 
of blood into the trachea in operat- 
ing, 401 
Langenbeck, case of extirpation of the 
larynx, 404 
operation for fibroma of nares, 244 
Laryngeal catarrh, dependent on chronic 
follicular pharyngitis, 101 
dependent on nasal catarrh, 272 
Laryngeal examination with head-mirror, 
8 
with Mackenzie's fixture, 6 
with Tobold's laryngoscope, 7 
Laryngeal mirror, method of holding, 9 

method of introduction, 9 
Laryngeal nerve, the sui^erior, 325 

the inferior, 326 
Laryngeal phthisis, 284 

differential diagnosis with syphilis 

309 
oedema of the glottis in, 283 
Laryngitis, acute, 267 
oedema in acute, 269 
rarity of acute, 267 
chronic catarrlial, 271 
chronic catarrhal of syi)hilis, 300 



424 



Laryngitis, chronic, caused by straining 
the voice, 273 

chronic, influence of the use of to- 
bacco on, 276 

chronic, paresis of tension in, 275 

chronic, the use of electricity in, 279 

subacute, 259 

subacute, of syphilis, 297 

subacute, rapid treatment of, 266 

ulcerative, of syphilis, 306 
Laryngoscope, Sass's, 4 

Tobold's, 4 
Laryngoscopy, direction of rays of light 
in, 11 

obstacles to, 12 

the image in, 13 
Laryngotomy, 384 
Laryngo-tracheotomy, 385 
Larynx, action in deglutition, 258 

anatomy of the, 253 

angiomata of, 368 

cicatrices in, from deep syphilitic 
ulcers, 312 

cystic tumors of, 367 

deep ulcers of syphilis in the, 311 

extirpation of the, 403 

fibromata of, 367 

lipomata of, 368 

malignant tumors of, 379 

method of making applications to, 59 

mucous patches in, 298 

myxomata of, 368 

papillomata of, 366 

physiology of, 257 

sarcomata of, 378 

semi-malignant tumors of, 378 

stenosis of, 318 

syphilis of, 297 

oedema of, 279 

tumors of, 365 
Leiferts. case of hemorrhage from exci- 
sion of the tonsils, 137 

case of hypertrophy of the turbinated 
bone posteriorly,. 204 

cases of paralysis of the abductors, 
355 

modification of Rauchf uss' insufflator, 
46 
Lipomata of the larynx, 368 
Light-condenser, Mackenzie, 4 
Lincoln, electrodes for the vault of the 
pharynx, 203 

electrolysis in fibrous tumor of the 
nose, 244 
Lozenges, the use of, in acute pharyngitis, 
81' 

Maas, case of extirpation of the larynx, 
404 
second case of extirpation of the 
larynx, 404 

Mackenzie, case of paralysis of the abduc- 
tors, 354 



Mackenzie, cases of paralysis of the ab- 
ductors, 359 
curette for vault of the pharynx, 208 
dilator for laryngeal stenosis, 321 
double tonsillotome, 140 
electrode for laryngeal paralysis, 343 
guarded wheel ecraseur, 376 
inhaler, 63 
laryngeal brush, 49 
laryngeal forceps, 372 
naodification of Physick's tonsillo- 
tome. 138 
pocket tracheal canula, 392 
rack movement fixture, 6 
tube forceps for larynx, 374 
use of London paste in enlarged ton- 
sils, 136 
Mann, Dr. M.D., on the pathology of en- 
larged tonsils, 128 
Matthieu's tonsillotome, 141 
McCreery, Dr. J. A., case of paralysis of 

the abductors, 352 
Medication, internal, vahie of, in laryngeal 
syphilis, 315 
local, value of, in laryngeal syphilis, 
815 
Membranous sore throat, 107 
Mercury, in chronic laryngitis of syphilis, 
304 
in deep syphilitic ulcers in the pha- 
rynx, 150 
Meschede, case of paralysis of the abduc- 
tors, 356 
Michel. Dr. Carl, on the source of ozsena, 

227 
Miller, Dr. John, case of pharyngeal tu- 
berculosis, 155 
Mirror, the laryngeal. 2 
Morphia, the local action of, in laryngeal 

diseases, 305 
Mucous membrane, lining the larynx, 257 
lining the nares, 168 
anatomy of, 33 
inflammation of, 38 
physiology of, 36 
Mucous patches in the larynx, 298 
in the nose, 231 
in the pharynx, 145 
Muscles, the aryteno- epiglottic, 257 
the arytenoid. 256 
the crico-arytenoid, 255 
the crico-thyroid, 255 
the thyro-arytenoid, 255 
the thyro-epiglottic, 257 
Myxomata of the larynx, 368 
of the nares, 238 

Nares, anatom.y of the, 166 
foreign bodies in the, 250 
mucous patches in the, 281 
physiology of the, 169 
proper definition of the boundaries of 
the. 171 



ITs^DEX. 



425 



Nares, tumors of the, 238 
Nasal catarrh as a cause of chronic laryn- 
gitis, 273 

a cause of chronic pharyngitis, 85 
Nasal cavity, method of examination of, 

22 
Nasal douche, danger of using the, 54 

in chronic coryza, 184 
Nasal polypus, 238 

fibrous, 243 
Nasal specula, 23 
Navratil's dilator for laryngeal stenosis, 

322 
Necrosis of nasal bones in syphilis, 234 
Nerves of the larynx, 257 

of the nares, 108 
Neuralgia of the larynx, a symptom not a 

disease, 328 
Neuroses, hystero-, of the fauces, 164 

of the larynx, 325 

of the pharynx, 162 
Newman's spray tubes, 58 
Nitrate of silver, in acute follicular ton- 
sillitis, 126 

in hyiDertrophic nasal catarrh, 198' 



(Edema glottidis, 279 
Oztena, simple, 227 

simple, no ulceration in, 229 

syphilitic, 231 



Palate, anatomy of the, 76 

author's canula for tying the, 29 
Wales' method of tying the, 29 
Papillomata of the larynx, 366 
Parsesthesia of the larynx a symptom, not 

a disease, 328 
Paralysis, bilateral, of crico-arytenoidei 
laterales muscles, 337 
bilateral, of crico-arytenoidei postici 

muscles, 348 
bilateral, of' the thyro-arytenoid mus- 
cles, 338 
double recurrent laryngeal, 332 
in general, treatment of, 341 
of mdividual laryngeal muscles, 333 
of the arytenoid muscle, 340 
of the crico-arytenoidei postici mus- 
cles, post-mortem examination in, 
301 
recurrent laryngeal, 329 
unilateral, of crico-arytenoideus later- 
alis muscle, 337 
unilateral, of crico-arytcnoideus posti- 
cus, 335 
Penzoldt, case of paralysis of the abduc- 
tors, 354 
Pharyngitis, acute catarrhal, 77 
acute follicular, 98 
chronic catarrhal, 81 
chronic catarrhal, aggravated by in- 
temperate habits, 84 



Pharyngitis, chronic catarrhal, aggravated 
by the use of tobacco, 83 

chronic catarrhal, dependent on dys- 
pepsia, 84 

chronic follicular, 100 

chronic follicular, producing laryn- 
gitis, 273 

croupous, 107 

sicca, 89 

sicca, influence of occupation in pro- 
ducing, 89 
Pharyngotomy, subhyoidean, 401 
Pharynx, anatomy of the, 74 

deep ulcers of syphilis in the, 148 

examination of the, 18 

examination of the vault of the, 31 

herpes of, 162 

method of making applications to the, 
61 

physiology of the, 77 

strumous ulceration of the, 152 

superficial ulcers of syphilis in the, 147 

tuberculosis of, 155 

vault of the, 172 
Phthisis of the larynx, 284 
Physiology of the larynx, 257 
Phonation, function of the larynx in, 258 
Pilcher's tracheal dilator, 387 
Polypus, gelatinous, of nose, 238 
Powders, alterative, 416 

astringent, 415 

stimulating, 416 

the topical application of, 45 
Prevention of a cold, 69 
Prophylaxis of a cold in the head, 175 

Quinsy, 112 

Rauchfuss' powder insufflator, 45 
Recurrent laryngeal paralysis, 329 

double, 332 
Rehn, case of paralysis of the abductors, 

355 
Resolvent solutions, 41 4 
Respiration, function of the larynx in, 258 
Respiration, nasal, 109 
Reyher, case of extirpation of the larynx, 

405 
Rhinoscopic mirror in position, the, 27 
Rhinoscopy, holding the mirror in, 26 
obstacles in, 28 
the parts seen in, 30 
Richardson's atomizer, 55 
Riegel, case of paralysis of the abductors, 

353 
Robinson, Dr. Beverley, case of paralysis 
of the abductors, 357 
evulsion forceps in hypertrophic na- 
sal catarrh, 197 
rubber balloon in epistaxis, 248 
Roger's tracheal canula, 388 
Roosa, danger of the use of nasal douche, 
54 



426 



INDEX. 



Rosenthal, on the method of taking cold, 

64 
Rubio, case of extirpation of the larynx, 

405 



Sanguinaria, use in dry catarrh of the 
nares, 21G 

use in dry catarrh of the pharynx, 92 
Santorini, cartilages of, 254 
Sarcomata of larynx, 378 
Sass' spray tubes, 5G 

tongue depressor, 20 
Sayre's uvulatome, 95 
Scarification in acute tonsillitis, 118 
Schmidt, case of extirpation of the larynx, 

404 
Schonborn, case of extirpation of the 

larynx, 404 
Schroetter's bougies for laryngeal stenosis, 

320 
Scrofula, a cause of enlarged tonsils, 127 

differential diagnosis from tuberculo- 
sis and syphilis in the pharynx, 159 
Sedative solutions, 414 
Seitz, on the method of taking cold, 64 
Semon, case of hysterical aphonia cured 

by threat of actual cautery, 347 
Sense of smell, 169 
Sexton's tongue depressor, 20 
Shaw, Dr., explanation of the pigeon- 
breast m enlarged tonsils, 132 
Shurley, nasal specalum and guard, 2:14 
Siegle's principle of atomization, 62 
Simrock's nasal speculum, 24 
Smith, Dr. A. H., canula for applying 
nitric acid in the nares, 197 

case of paralysis of the abductors, 357 

powder insufflator, 46 
Snoring, in enlarged tonsils, 131 
Snuffs, 415 
Solutions, alterative and resolvent, 414 

aqueous, 410 

astringent, 412 

cleansing, 411 

disinfectant, 414 

sedative, 414 

stimulating, 413 
Spasm of the glottis, from elongated 
uvula, 94 

in enlarged tonsils, 134 
Sphenoidal sinuses, the, 167 
Steam atomizer, the, 61 

use of, in acute tonsillitis, 117 
Stenosis of the larynx, 318 

analogous to urethral stricture, 319 

in nasal catarrh, 187 
Stimulating applications in chronic nasal 

catarrh, 210 
Stimulating powders, 416 

solutions, 413 
Stoerck's laryngeal forceps, 375 

powder insufflator, 47 



Syphilis, a cause of bilateral paralysis of 

the abductors of the larynx, 360 
differential diagnosis from phthisis 

and scrofula in the pharynx, 159 
differential diagnosis from laryngeal 

phthisis, 309 
of the larynx, 296 
of the larynx, deep ulcers-in, 311 
of the larynx, superficial ulcers in, 306 
of the pharynx, 143 
of the pharynx, deep ulcers in, 148 
of the pharynx, superficial ulcers in, 

147 
of the pharynx, mucous patches in, 

145 
of the nares, 231 . 

of the nares, local treatment of, 235 
Syringe, the post-nasal, 51 



Taking cold, theories concerning, 64 
Thudichum's syphon douche, 53 
Thyro-arytenoid muscles, 255 

bilateral paralysis of, 338 

unilateral paralysis of, 340 
Thyro-epiglottic muscle, 257 
Thyroid cartilage, 253 
Th'yrotomy, 399 

in laryngeal stenosis, 324 
Tobacco, the use of, as affecting diseases 

of the fauces, 83 
Tobold's concealed lancet for scarifying 
the larynx, 283 

laryngeal forceps, 371 
Tongue depressor, method of introducing 
the, 21 

pocket-folding, 19 

U. S. A. pattern, 19 
Tonsillitis, acute, 112 

paralysis of faucial muscles in, 114 

acute follicular, 123 

subacute, 119 
Tonsils, anatomy and physiology of the, 
111 

excision of, during subacute tonsil- 
litis, 122 

hypertrophy of the, 127 
Trachea, exposure of, in tracheotomy ,396 

opening of the, in tracheotomy, 397 . 
Tracheal canula, insertion of, 397 

Durham's, 389 

Gendron's bivalve, 391 

Howard's improvised, 393 

Mackenzie's pocket, 392 

ordinary double, 389 

Rogers', 388 

Trend elenberg's, 400 

Trousseau's, 388 
Tracheal dilators, 387 
Tracheotomy, 385 

anaesthesia in, 394 

exposure of the trachea in, 396 

hemorrhage in, 395 



INDEX. 



427 



Tracheotomy, in laryngeal phthisis, 295 
instruments used in, 886 
in paralysis of the abductor muscles, 

selection of site for, 398 
Trendelenberg's tracheal canula, 400 
Trocar, for tracheal canula, 390 
Trousseau's tracheal canula, 388 

tracheal dilators, 387 
Tuberculosis, differential diagnosis from 
syphilis and scrofula in the pharynx, 
159 

of the larynx, 285 

of the pharynx, 155 
Tuerck's laryngeal brush, 48 

tongue depressor, 19 

on chorditis tuberosa, 368 
Tumors of the larynx, 365 

benign, 366 

malignant, 379 

semi-malignant, 878 

the removal of, 870 



Ulceration, deep, of laryngeal syphilis, 
differential diagnosis in, 314 
superficial, of laryngeal syphilis, dif- 
ferential diagnosis of, 314 
deep, of syphilis of the nares, 233 
superficial, of syphilis of the nares. 



Uvula, elongation of, 93 
method of removal, 95 



Vault of the pharynx, anatomy of the, 172 
a part of the nasal cavity, 171 
curette in glandular hypertrophy, 907 
not the seat of a fetid catarrh, 322 

Ventricle of the larynx, 255 

Ventricular bands, 255 

Vocal apparatus, Gussenbauer's, 409 



Vocal apparatus, Foulis' modification of 

Gussenbauer's, 409 
Vocal cords, 254 

Voice, function of the nares in modifying 
■ the, 170 

in acute pharyngitis, 78 
impaired, in the deep syphilitic ulcers 

in syphilis, 813 • 
in enlarged tonsils, 131 
mechanism of the, 258 
rest of, in chronic follicular pharyn- 
gitis. 105 
rest of, in chronic laryngitis, 278 
straining the, 273 

weakened by chronic laryngitis, 274 
Von Bruns, case of extirpation of the 
larynx, 405 
epiglottic pincette, 12 



Wagner, bougies in hypertrophic nasal ca- 
tarrh, 196 
si^onge-tents in hypertroi3hic nasal 

catarrh, 195 
Wales' method of tying the palate, 29 
Walker, Dr. H. F., case of paralysis of 

the abductors, 352 
Warren, case of paralysis of the abductors, 

356 
AVeber, case of paralysis of the abductors, 

358 
Weerner. case of extirpation of the larvnx, 

405 " . 

Whipham, case of paralysis of the abduc- 

.tors, 358 
Whisper, method of production, 261 
Whistler's cutting dilator for laryngeal 

stenosis, 828 
Wrisberg, cartilages of, 254 



Ziemsseh, case of paralysis of the abdiic- 
tors. 354 



